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08/26/05 TUE 11:48 FAX 5100 4141 GEO�IgTRIX OAKLANT 015 <br /> w <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 FILE COPY <br /> NON-REFUNDABLE PERMrrEXPIRES R FROM DATE ISS U Ilcatlon is made in com Ilance with San <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This app p <br /> Joaquin County Development 7iitle,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department.Assessors <br /> WELL Location FSS Q(J Cross Street �Tg{X115 �� City r Zip�tSs-tcD Parcel# <br /> rS� �� Phone#qZS-842-_1343 <br /> PROPERTY Owner r o�ek4c ,L11ans1wLi1_Addn �0. goL (no17 CltySo�CLQ w� ZiPgg_. <br /> C-57 Contractor G � _Address`ISO Kavx 2J Cityy.na N c*- Zlpr 4.5$-� Lic#`?5IbS Phone#`Z2�-3t'�Sgt <br /> tr St I,& t Clty0a.- rd Lic# Phone# SIo-r�t. -4kw <br /> Consultant/Sub CntrGcoww{ s o�sulkr ` AddreSs��l_— �— <br /> GIS Coordinates'X <br /> Y Townshlp Range Soctlon <br /> WORK T BE PERF D: <br /> KNEW WELL GRIN (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGE ,OTHER" p DEUS�TR R BO ON DiAMETERpe below) <br /> ?p!SOIL BO FI �r'^^X l N^�^a� �'t'Y-1� PRESSURE GROUT <br /> I]-WELL# GROUT SPECIFICATIONS <br /> Q"Other <br /> COMMENTS: e <br /> TYPE OF WELL INSTALLATION TY E CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2,5' n MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA:tJ�_ <br /> MA <br /> []EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS t0A TYPE I E 0 BE STEEL 0 V []PC Q OTHERERS HOSE <br /> D VAPOR p MUD ROTARY DEPTH OF GROUT SEAIT�TREM ETYP <br /> 0 AIR SPARGE/OZONE'XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER- 0 OTHER_,,,_, APPROX.BORING DEPTH tit: BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NA _Of YES,list specifications in comment section) <br /> COMMENTS: orY.'rs {ct,.�c.�,.�� Sc.�„ \w1,_!. + 5 �- <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, R les and Regulations,and all applicable California State Laws. <br /> Title/Company <br /> Signed x <br /> rr Date <br /> Print Namet <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: �- � � Q /�/1/ <br /> Date IlUued U 6 � Area "`�I <br /> Application Accepted By Date ai 34 <br /> Grout Inspection By Data Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONIATIONS: <br /> ACCOUNTING ONLY: AlD# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 2�0 O Z gZS SR# S�ZO <br /> C-57 WC -WAIVER— C-57 Letter of authorization to sign permit Encroachment doc_ 9/30/02 <br />