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10/08/2002 10:47 2094683433 <br />FIFTH FLOOR 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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location goid 3 2 Sixern.,e t t. Cross Street 7;1 , ary , , Assessors_ <br />Zp r"Li_Parceitt — 3d4 — <br />WORK TO BE PERFORMED: <br />)(NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />p6OIL BORING # B — (1- <br />WELL # <br />(1.'Other <br />COMMENTS: <br />a DESTRUCTION (choose type below) <br />OVER-BORE. DIAMETER <br />fl PRESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <br />sz) <br /> <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />() MONITORING )(HOLLOW STEM DIA. OF BOREHOLES ;•1. 0 MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: <br />Li EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS //1/ M- TYPE OF CASING! (I STEEL f] PVC II OTHER: <br />a VAPOR n MUD ROTARY DEPTH OF GROUT SEAL 7' it. TREMIE TYPE TO BE USED: [JAUGERS I] HOSE <br />U AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: X Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />XSOIL BORING p HAND AUGER GROUT SPECIFICATIONS & -ea r E eme.t — <br />a OTHER: a OTHER APPROX. BORING DEPTH 7t1 4 /. lj BOLTED TRAFFIC BOX or 13 STOVE PIPE <br />CONDUCTOR CASING PROPOSED N 0 (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 a d egulations, and all applicable California State Laws, <br />Signed x ,,etter' <br /> <br />Title/Company pt2,0.16-,cr Pnuovz--/rize-- <br /> <br />Print Name Een-f p erer-r-- <br />DEPARTMENT USE ONLY <br /> <br />Date <br /> <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />4pplication Accepted By C <br /> <br />Date Issued //.370 <br />Date //aVo3 Final Inspection By <br />Date <br /> <br />Area OY <br /> <br />3rout Inspection By /pi, <br /> <br />Date <br /> <br />Destruction Inspection By <br /> <br />30MMENTS / CONDMONS. <br />ACCOUNTING ONLY: AID# <br />..r, <br />FAC# L. <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVIC - T # INVOICE <br />4,i! //1;/42 oil SR# N) 32-21 '7 <br />SITE <br />MITIGATION <br />U NIT IV <br />PROPERTY Owner 7;era /01 J, er 14ns Address .1 Po S. Sic tt-4 ovIen -t; ft City Loot Zip 'P V-61Phone# <br />C-57 Contractor (.-roA) ,Of, X!) Address 9 6-8 /210 Ali City A//41-/Cii'zZip 9$433-3 Ljc# egYe/Phonetl (237) ...?/S — .5100 <br /> <br />ek.toryt 69',Z fj Of —400 Consultant Sub Cntr Address Lic# Phone# <br />GIS Coordinates: X , Y , Township Range Section <br />C-57 Wc -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit ncroothmen <br /> <br />9/30/02 <br />