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07/14/2003 14:01 9168610430 <br />SECOR <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 48$-3449 <br />PAGE 02/02 <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR—MOM—DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. This application Is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />I - Assessors <br />WELL Location Z -72,S 6ou r,-`rj GI U6 Q1vd Cross Street 4 � Clty Zlp 0(� 2oq Parcel# <br />PROPERTY <br />Owner_ - IQvP,n,yC Address City 00114_C-"—xZIp7SLZI Phonn# <br />QSGaC Dr11 1, RF Address 3632 O�c (-;r mho <br />C-57 ContractorcS <br />C11y Cort#cyi; Zip gS7�{�Llc#,� I iSlbPhone# (ql6 G384 <br />Consultarti/Sub Cntr �LHCOrL n+ernafionQiAddress3�7 K;t3or2 Rk Stft�lty A jCW Lic# 654u(Q$ Phone#016061-0400,X24 <br />GIS Coordinates: X 'y Township N Range (73 L Section <br />WORK TO BE PERFORMED: <br />')(NEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") U DESTRUCTION (choose type below) <br />KSOILBORING# Sb -9- DOVER -PORE. DIAMETER <br />DWELL # f hyi~R [] PRESSURE GROUT <br />0 `Other_ GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELD INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING XHOLLOW STEM DIA, OF BOREHOLEJ�i 0 MULTIPLE CASINGS [] MULTI-LEVEL WELL CASING DIA: <br />a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSSOIN TYPE OF CASING- (ISTEEL )jPVC 0 OTHER: <br />0 VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL .� TREMIE TYPE TO BE USED, XAUGERS U HOSE <br />0 AIR SPARGE! OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: X Yes [] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />$SOIL BORING n HAND AUGER GROUT SPECIFICATIONS Nea+ Cey-e„i <br />p OTHER: 0 OTHER APPROX. BORING DEPTH_ Sp` bgS BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED No (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS, <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County (Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x 1� 7 �"" 4P Title/Company fl Q1eC+_ G�o�oS f Str— $ LOiz �n 4erngi it,na� enc. <br />Print Name 1J r G V\ (�_4 r eDate -7/1Lt <br />I Q <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: '279 <br />5- <br />WORK PLAN DATED: __, /-PD- <br />Appllcation Accepted By <br />Grout Inspection By„_ <br />Destruction Inspection By <br />COMMENTS / CONDITIONS - <br />ACCOUNTING ONLY: I AID# <br />Date Issue <br />Final Inspection <br />Date <br />FAC# <br />PE CODES I FEE INFO I AMOUNT REMITTED I CHECK # <br />'3jrd <br />C-57 <br />RECD BY DATE <br />-WAIVEP— C-57 Letter of Authorization to sign perm <br />SR# <br />L <br />INVOICE <br />9/30/02 <br />