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10/14/2002 13:01 2099412574 ir,(14(4auz id:A) 2054683433 FIFTH FLOOR <br />PAGE 1 0 <br />PAGE 02 <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (END) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDARLE_PERMIT EXPIRAS 1 `MAR FROM DATE ISSUED <br />Applic.atIen Is hereby made to San Joaquin County fo(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 />Asaessors DA4A,,-e_1 Cross StreetiktlfrJAlerC"JCltY erif ZIp 4-5-2e( Rarcet# <br />2..-a PROPERTY Own arii de-"Cr-Cei Add res62,,,41.22.i.6,4,41.4_re‘,ILCity_sZT 21p.Z,r2,e4 Phoneal VG <br />Contracto,D (17P.E6& R-ILLiAd mas q(co i-b-tg: A-1 _ Lio/M7C165' oo <br />Consultant / Sub Cntr Arldress <br /> <br />Clty Lic# Phone# <br /> <br />GIS Coordinates! X , Y . Township Range <br />WORK TGli3E PERFORme,p; <br />X.NEW WELL / BORING (OPT. GEOPROBE, HYDROPUNCH. HAND-AUGER OTHER') u DESTRUCTION (choose type below) <br />0 SOIL BORING# . <br />OWELL # 3 Ilkt Le...A.4,4A_, co. /tot 54. <br />n OVER-BORE. DIAMETER <br />SITE <br />MITIGATION <br />UNIT IV <br />WELL Location 9-111 <br />Secton <br />0 •Othar <br />COMMENTS: S56" ArTACtIED ,MA-p /Vv..) 1 /4.1 /4/ 4/- p.4E-rRAA4 12-0 1.( GROUT SPECIFICATIONS <br />U PRSSuRE GROUT <br />t:),F WELL <br />X.IONITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE/ OZONE <br />0 SOIL ORING <br />OTHER. <br />CON,STRUCTIQN SP_ECIFICATIONS <br />DIA. OF BOREHOLE 8" a MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA; 2 " <br />CASING TH CKNESS g.CH 40 TYPE OF CASING: 0 STEEL XPVC BOTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS U HOSE <br />çj PUSH POINT (OF or CPT) GROUT SEAL PUMPED: 0 Yes J No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />n HAND AUGER GROUT SPECIFICATIONS <br />n OTHER APPROX. BORING DEPTH 30 BOLTED TRAFFIC BOX or ZSTOVE PIPE <br />INSTALLATION TYPE <br />XkOLLOW STEM <br />fl Al R HAMMER/DRIVEN <br />D MUD ROTARY <br />CONDUCTOR CASING PROPOSED (if YES, list specilication.s in comment section) <br />COMMENTS! E Arrifa-Ctl tA) O/4etre4/4/ <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />i ',ereby certify that I <br />County Ordinan , <br />Signed x <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br /> Date Issued 8/7-1)(122-- Area Lo /7 <br /> Date /7-403 Final Inspection By <br />Date <br />CoMME NTS 1 CONDITIONS: 74 -it tLI Atr7 LP <br />ACCOUNTING ONLY: <br />iv <br />AID# PI:1 /40# —1 <br />PE CODES EE INFO AMOUNT REMiTTED CHECK # REC'D BY DATE PERMILLEERVIC : QUEST! INVOICE <br />35:o 5 --- P alt4, 645714 . tZ,* ii 2_,. 0 5R#() 7 ... <br />have prepared this application and that the work will be done in accordance with an Joaquin <br />tiles and Regulations, and all applicable California State Laws. <br />P f- Pectiect tA/aprote.-.1 accit1o4 <br />10. de,4 ,4.eTif-- Date ( A410 2 <br />DEPARTMENT USE ONLY <br />Ttle/Com pany <br />knlIcation Accepted By <br />Inspection By <br />Destruction Inspection By <br />Dale <br />C-57 -WA:VER C-57 Letter of Authorization TO sign permit 9/30/02