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10/08/2002 10:47 2094683433 FIFTH FLOOR <br />PAGE 04 <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) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM 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 8-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />LL ,, Assessors WELL Location )U 9 - /Po S: rci.e.,h, Sr. Cross Street raAr.tk 4r. City 1- 6 41,. Zip 7-Q T1/ Parcelft St-37---Z /a - <br />PROPERTY Owner We "'co No /Z -TA . Address AZ 9' St Sclera 4-141 t-c St. city L6-4/ ; Zip Vaphone# <br />61r e‘5.5 II; <br />Consultant / Sub Cntr TR <br />GLS Coordinates: X ,Y Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />ANEW WELL I BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br />SOIL BORING # SR - 3 <br />LI WELL # <br />fl 'Other <br />COMMENTS: <br />u DESTRUCTION (choose type below) <br />1:1 OVER-BORE. DIAMETER <br />(1 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br />C-57 Contractor Address /1"' 8 ied • City *At 1-;ilez Zip 9,045YUciti 67.579O7 phone# (,.Z.5-)313 -S7 a <br /> Address 5-P3), Cr, city Phone# (9,?5-) tret -/-? <br />TYPE OF WELL <br />I] MONITORING <br />I] EXTRACTION <br />VAPOR <br />a AIR SPARGE/ OZONE <br />)(SOIL BORING <br />OTHER: <br />INSTALLATION TYPE <br />)(HOLLOW STEM <br />a AIR HAMMER/DRIVEN <br />MUD ROTARY <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 6:4 a MULTIPLE CASINGS fl MULTI-LEVEL WELL CASING DI/': F/4 <br />CASING THICKNESS /V/A- TYPE OF CASING: if STEEL f] PVC a OTHER! N/A <br />DEPTH OF GROUT SEAL 76/ 4t, TREMIE TYPE TO BE USED; XAUGERS UHOSE <br />Li PUSH POINT (GP or CPT) GROUT SEAL PUMPED: Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />fl HAND AUGER GROUT SPECIFICATIONS NeA F CeP4 e t — <br />o OTHER APPROX. BORING DEPTH 70 ft,U BOLTED TRAFFIC BOX or LI 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 Regulations, and all applicable California State Laws. fri <br />0E---6•2-i ~Geri — <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />PeA P irtr-CrZ4.4 Title/Company <br />2-10 3 Date <br />4pplication Accepted By <br />Drout Inspection By <br />Destruction Inspection By <br />4 9 Date / Final Inspection By Date <br />Date <br />Date Issued ft.54,1 <br /> <br />AreaDy <br /> <br />;OMMENTS / CONDMONS. <br />ACCOUNTING ONLY: AID# FAC# <br />,..,. <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE '- • r REOUES INVOICE <br />L57°1 Ecc 59- V7, (-1-/ V3 SR# 60 -Z-Z.7(., 1 <br />C-57 WC <br /> <br />-WAIVER <br /> <br />C-57 Letter of Authorization to sign permit E <br /> <br />9/30/02 <br />