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JUL-29-2003 09:23 CAMBRIA 1707 '33RRIGINA1 <br />WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 C) <br />NON-REFUNDABLE PERMIT EXPIRES.1 YEAR FROM DATE ISS -110 <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 8-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessors <br />WELL Location (U Oa� "n r ALL Lk- Cross )Sttreet e (K.CI <br />�v zip 5-Z 04 Parcel# W3- <br />41 15 <br />�/ Ga-C -PROPERTYOwnei Ciy1Z0 ��Phone ) <br />C-57 Contractor ['7Q-44 Address �0 o Ci nt2 Zip �5$ Lic#� bg0"t' PhonA25 3 Q 55lp0 <br />Consultant I Sub <br />GIS Coordinates: X tibs �AA�O"TL hl Y 42035�q m Township Range ____ Section <br />WORK TO BE PERFORMEDS _ <br />gNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) [I DESTRUCTION (choose typo below) <br />[] SOIL BORING # __ Q OVER -BORE. DIAMETER <br />0 WELL # [) PRESSURE GROUT <br />1VOther _____— GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />[] MONITORING Q HOLLOW STEM DIA. OF BOREHOLE [I MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: � <br />[] EXTRACTION [] AIR HAMMERJDRIVEN CASING THICKNESS TYPE OF CASING: O STEEL IIPVC D OTHER: -1 <br />p VAPOR [] MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [] AUGERS p HOSE <br />[] AIR SPARGE/ OZONE [] PUSH POINT (QP or CPT) GROUT SEAL PUMPED: I) Yee 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />p SOIL BORING [] HAND AUGER GROUT SPECIFICATIONS <br />BOTHER: GPT f1 OTHER APPROX_ BORING DEPTH p BOLTED TRAFFIC BOX or p STOVE PIPE <br />CONDUCTOR CASING PROPOSED (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 Ord S, ulTa�1an.,drRegulations, and all applicable California <br />' State, L�aw/Js�. ,'� <br />Signed x/'7!Ir TitlelCompany �f ,� ` �5r'i('L�/Nbn 6nokwm�+R` <br />Print <br />SITE MAP IN UNIT IV FILE, ADDRESS: . �L'10 7 Cy C-�c-t/3 .�� wl� <br />WORK PLAN DATED: 11—'19 —.6 <br />Application Accepted By �'�5'/�- Date Issued ' L ' �3 Area ()1, <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection By Data <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED CHECK # REC'D ATE PERMIT/ SERVICE REQUEST* <br />INVOICE <br />b / <br />S 1-44c)•ZZ it~ # b0 'J <br />C-57_ WC v/-WAIVER� C-57 Letter of Authorization to sign permitachment dock 9/30/02 <br />TOTAL P.02 <br />