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09/25/2002 13:16 2094683433 <br />FIFTH FLOOR <br />I I . ­\ 1 • WELL PERMIT APPLICATION FORM <br />E� <br />PAGE 03 <br />SITE <br />R <br />ATI <br />SAN JOAQUIN COUNTY MITIG <br />�I-I � ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />ON <br />WN ,ca�N�� 304 E. Weber, Third Floor Stockton CA., 95202 <br />ONE� Ny\GE , p, (209) 468-3449 <br />p�6�MFN-gq� <br />1v� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application IS hereby made to San Joaquin County for a permlt to construct and/or install the work described. This application is made In compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards Of San Joaquin County Environmental Health Department. <br />~- t o A t G H r 5 G F- WA 'Y S H F. Ik M A N Assessor's <br />WELL Location m CF F A r BLV D. Cross Street tv 4 N V E City MA h T ECA Zip -)5;3(1 Parcel# <br />CIT1 CF MANI17ECA <br />PROPERTY Owner P %ia0L WC(21 5 Dim -PE, Address (CCI W.C.CNTE13 5T Cityi'IAt tVA zp9S3-3}Phone#CZC-)jaj3-"jj9c <br />VAI i J7 \.r <br />C-57 Contractor <br />t10)1T2-3540 <br />Consultant /Sub Cntr I. n M A t L CNV Address PG 13 G X ``/+ tic N G <br />) CityM� Phone# 3 i S p <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED - <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />/ SOIL BORING # S (3-,), I C, I; II r 0 OVER -BORE <br />d WELL # 1] PRESSURE GROUT <br />'Other: Grout Specifications: <br />COMMENTS <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE / Ozone III PUSH POINT <br />II SOIL BORING <br />0 HAND AUGER <br />0 OTHER: <br />0 OTHER <br />'COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE Z"iN MULTIPLE CASINGS? 0 MULTI-LEVEL? 0 WELL CASING DIA: MA <br />CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC BOTHER: <br />DEPTH OF GROUT SEAL ro ;� 2 5 r TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30) <br />GROUT SPECIFICATIONS: N C A T L E h E N T <br />APPROX. BORING DEPTH .Z 5 "- r r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? Nit; (if YES, list specifications here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />:ounty Ordinances, Rules and Regulations, and all applicable California State Laws. 1 '' <br />iigned x_ _ TItle/Company <br />'rant <br />Y <br />;ITE MAP IN UNIT IV FILE, ADDRESS: 33'l 5. M C F FA t l3 C A L f V A Ik p� MA NtL C A <br />YORK PLAN DATED: 3- 1 t L k; I <br />,pplication Accepted By Date Issued 1 I Z k "Z Area_ <br />rout Inspection By Date 2- , 2 Final Inspection By ��. , 1��.c"� Date 4'2 <br />lestruction Inspection By Date <br />OMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT/ SERVICE REQUEST # <br />INVOICE <br />lit zl Ir <br />SR# r <br />-57 WC-___ WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc� 8/29/02 <br />SRue -2, <br />t,- <br />