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10/08/2002 10:47 2094683433 <br /> <br />FIFTH FLOOR PAGE 04 <br />WELL PERMIT APPLICATION FORM SITE SAN JOAQUIN COUNTY y 'MITIGATION ENVIRONMENTAL HEALTH DEPARTMENT (-E Dy UNIT IV 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 JAN 0 3 2003 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'WENT HEALTH <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appliaitieRtg'S ii14acin Compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessors WELL Location )/21 )304 S Sat vAIA-€6-1-0 Cross Street 7-Amur1kt/s tif , City zip 7S -2 ro parcei# ;TV.5--.ego-ag. <br />PROPERTY Owner pewC0 1/0 /Z. 1-6 ,C- Address IP, s, s atrAivie,h, 2f. City /./v/, Zip 5-2 (-)Phone# <br />C-57 Contractor & v E Pr; Pi) Address 3L 17' 01A- , City z zip 7Y:5-S-3 Lie:106iI 772 7 Phone # (92 5") 31s <br />Consultant / Sub Cntr Address vh ei r)Ai 616/ eco.ez• Lic# Phone# (3'23-)6'8t - ea <br />GIS Coordinates! X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />XNEW WELL I BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />ASAOIL BORING # <br /> . <br />- <br />ELL # <br />"Other <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING %HOLLOW STEM NA. OF BOREHOLE, 6';‘, 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA! Nth <br />0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS isi /A- TYPE OF CASING: n STEEL 0 PVC a OTHER! <br />0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL -77 ,/-. TREMIE TYPE TO BE USED: "(AUGERS U HOSE <br />U AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: Ryes fl No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />)(SOIL BORING ti HAND AUGER GROUT SPECIFICATIONS Alexi- ee.ev±" <br />U OTHER: a OTHER APPROX. BORING DEPTH 7t9 ft--. g BOLTED TRAFFIC BOX or a 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 />Count Ordinances, Rules R ulations, and all applicable California State Laws, <br />Signed ...0-4-s-•-jr- <br />Print Name <br /> <br />DEC-Pka,f <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT N FILE, ADDRESS: <br />WORK PLAN DATED: <br />4pplication Accepted By Date Issued <br /> <br />Area Cilatio&a2( <br /> <br />O DESTRUCTION (choose type below) <br />OVER-BORE. DIAMETER <br />I] PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />Title/Company PgOcifel" PA/Z(-677,42/772,-C_- <br />Date I/14 b3 <br />2rout Inspection By <br />Destruction Inspection By <br />:-.0MMENTS / CONDITIONS. <br /> <br />Final Inspection By <br /> <br />Date <br /> <br />Date <br /> <br />ACCOUNTING ONLY: AID# FAC# <br />..s, <br />L <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE QUEST • INVOICE <br />39)1 Fl — 9 - U7? I 144 <br />C-57 WC <br /> <br />-WAIVER <br /> <br />C-57 Letter of Authorization to sign permit <br /> <br />9/30/02 <br />