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01/15/2004 14: 34 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> County for is permit to wnstnxtandlor Install the work descnbetl- This application Is made in compliance with San <br /> Application is hereby made to San Joaquin <br /> Joaquin County Development Tide,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health DeparlmenLAssessors <br /> Zip YS.Z S� <br /> WELL Location11 o Py'Lcross street 0. ✓r s"fib d<CLR�,U�.- .- —ParcelY: <br /> (�A / -�� � .Address aZ 00� '4uC-CityZip � i_A1 phone-120l�/ _ III( <br /> PROPERTY Owner/ 1 lV�P I.GIf`L`I_la. pp (,i.3o)66.z-2B.?y <br /> C•51 Controctorw E `�z TI UI AddressP Ilc X 141 Co Rd I41 City ZSV ovct Zip jg 78 Lic# Phon Grp <br /> ' p 7Addrems/ VcSV <br /> Ci� l SLc# <br /> 6 b aPh <br /> Consultant f Sub ConVaolorD � Range n� / Secotnioen <br /> GIS Coordinates:X 557 Townsh �j 3:�7e 6C0 <br /> �1/✓Z�S�y7 <br /> WORK TO BE PERFORMED: 0 DESTRUCTION(choose type below) <br /> EW WELL f BORING(CPT.G OIL BOR.H#DROPUNCH,HAND AUGER OTHER') 0 OVER-BORE <br /> ELL# 0 PRESSURE GROUT <br /> Gmut Specifications: <br /> 'Other- <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION CONSTRUCTION SPECIFICA71 MULTIPLE CASINGS?I]YES le NO WELL CASING DIA.—P <br /> 1]MONITORING D HOLLOW STEM DIA,OF BOREHOLE, <br /> EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS SG ��'C'�)�''TYPE OF CASING: I]STEEL N PVC 0 OTHER: <br /> I VAPOR ®MUO ROTARY DEPTH OF GROUT SEAL�TREMIE TYPE TO eE USED: p AUGERS R HOSE <br /> OAIRSPARGE OPUSHPOINT GROUT SEAL PUMPED: lye$ allo (NOTE: M•�yyIMUMIFREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 1]HAND AUGER GROUT' ��r�O �I <br /> "GFS �t2�Tc I �7 ru ce t. .1-C <br /> 0 OTHER: U OTHER APPROX.BORING DEPTHS 0 IA BOLTED TRAFFIC BOX o�- 0 STOVE PIPE <br /> CONDUCTOR ASIN OP SED? 0 (if YES,list specifications here): <br /> C ' J <br /> 'COMMENTS' <br /> 4NOTE: OFFSITE BORINGS REQUIRE ACCESS R ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that a work will pe done Laws.in accordance with San Joaquin <br /> County Ordinanc ules and R u tionS,,and all applicable <br /> i� 'ride/Company o C ' <br /> Signed x, -'�LKHAN i AouA <br /> Da e <br /> PrintName_ _ DEPARTMENT U"SEONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: S 0 S1MG(u v 'Si <br /> WORK PLAN DATED' I <br /> Ove Issued_ p1 1 sT. Area <br /> Application Accepted BY Dat i L`1 Final Inspection By TTT Date <br /> Grout Inspection By_,, <br /> Destlurtion Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# r°rvr <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'DBY DATE PERMIT f SERVICE REQUEST# INVOICE <br /> oo 06 00 a so sIx 3683 <br /> C-57 WC__WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_- <br /> 1/25/ <br />