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08/26/03 TUE 11:47 FAX 5104141 ,�EO)LkTRIX OAKLAND10 C(DFIY <br /> 01� 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) 4683449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appllcation Is hereby made to San Joaquin County for a permit to constrict and/or install the work described- This application Is made in compilance with San <br /> Joaquin County Development Title,Chapter 8.1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> Assessors <br /> WELL Lrocation Q�l7 ''c�v�u�' Cross Street r .skN-V'11SDL-City �r ZipgSs IU Parcel# <br /> �-� S�H 2 p94_ �z <br /> PROPERTY Owner�nvv N N�c-K4 sha T�Atltlress�b�� �O12 Gity s arr,,�.., Zi S8 3 Phone# fi42- 13,f3 <br /> "7 Contractor G as �n 11� Address 9 9 }6i ac VJ4 City^c Zip_ _Lic# S1l,S Phone#� -5V 3-51�� <br /> Consultant/Sub CntrG Address210t Weh,,kr SA I1+h Ft.City 0akicv%6 Lic# Phone#Sto-1,c,3 Stoo <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERF <br /> XNEW WELL RI r Ir1PT.rF-OPROBE,HYDROPUNCH.HAND-AUGER,OTHER• n DESTRUCTION (atwo5e type glow) <br /> ,g,SOIL BORING# GMx- 17—'> GfaKZ S la OVER-BORE., DIAMETER <br /> 0 WELL# a PRESSURE GROUT <br /> p*Other GROUT SPECIFICATIONS <br /> COMMENTS: 11hollows 23 & c <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING `jHOLLOW STEM DIA.OF BOREHOL zE S-8 0 MULTIPLE CASINGS H MULTI-LEVEL WELL CASING DIA PA <br /> p EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: []STEEL Q PVC BOTHER: <br /> a VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL_TREMIE TYPE TO BE USED: GAUGERS XHOSE <br /> a AIR SPARGE/OZONEAPUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Jk601L BORING H HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER: rl OTHER APPROX.BORING DEPTH lel 40 g 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,fist specifications in comment section) <br /> COMMENTS: t �K' sc L 4 5 <br /> NOTE: OFFSITE BORIN S 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"and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Name Crr t�4'TrcPs,✓1 Date & 2-s O 3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> Date Issued � .3 Area 0 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# "FAG#PE CODES FEE INFO AMOUNTREMITTED CHECDATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# 35 D 19 <br /> C-57,/— WCWAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc� 9/30/02 <br />