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01/15/2004 14:34 209468343: FIFTH FLOOR • PAGE 02 <br /> WELL, PERMIT APPLICATION FORM SITE <br /> JUNSAN JOAQUIN COUNTY MITIGATION <br /> EIVVIriUNIUIENI IiEALNVIRONMENTAL HEALTH DEPARTMENT (END) UNITIV <br /> , <br /> PERMIT/SERVICES >�04 ( .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.As ',g <br /> WELL LacatloiLN SId.Q d W <br /> f asAlIi'$A{{Oct t Sk_.Cross Streetl�o+yj 1 Aa Y .CityS oC L0vI Zip 75-V SPar1# it: <br /> PROPERTY Owner f �00'I1PC(Address"206 'V, Wos te,- Ave. City to d✓t TpPhone#Lg <br /> c�s7 Contractor v�/ C- tF�� o�a��e�Address �• Ro//x INi,r(.o kd��ciry�Z(Q.+novµ �p QS6 Y8 uat Phone/ls3o�6-2 -asa9 <br /> Consultant!Sub CantrdctcrL)t & i-ASC e Uv44SAddressi705 I ;V� r,J,t. CityEh�f c#�60 yoZphoneill �� -sly <br /> GIS Coordinates:X a f ,Y " W .Township I /y Range R 7e Section SPL <br /> DRK TO BE PERFORMED: <br /> NEW WELL I BORING(CPT,GEOPROBE,HYDROI'UNCH,HAND-AUGER,OTHER-) 11 DESTRUCTION(choose typ;a below) <br /> SOIL SORIN it 13 OVER-BORE <br /> WELL# O PRF,SSIIRE GROUT <br /> *Other- - ., Grout Specifications: <br /> COMMENTS: --,—. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING d HOLLOW STEM DIA.OF BOREHOL 0' MULTIPLE CASINGS?Q YES 0 WELL CASING DIA:_ <br /> EXTRACTION (]AIRHAMMERIDRiVEN CASINGTHICKNESS C O ITYPEOFCASING: I]STEELON P <br /> VC 13 OTHER,, <br /> U VAPOR *MUO ROTARY DEPTH OF GROUT SEAL 3 TFtEMIE TYPE TO BE USED: n AUGERS *HOSE <br /> 13 AIR SPARGE p PUSH POINT GROUTSEAL PUMPED: *Yes No (NOTE: MAXIMUM FR E-FALL DEPTH IS 30') <br /> BSOIL BORING 13 HAND AUGER GROUT SPECIFICATIONS' t}� <br /> B OTHER: D OTHER APPROX.BORING DEPTH q Ci- BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED9 (it YES,list specifications here): <br /> 'COMMENTS, <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS INADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will jbe done in accordance with San Joaquin <br /> County Ord! s, Rules an Fjegulations, and all applicable California14 <br /> IStalte Laws. �3701_6 / <br /> Signed —r�-- //� •I( ✓ �rl l ll e✓ Title/Company 1 O(vo R o (ti 1 0 c 4A <br /> Print Name VUti T I ' `�r^' 0 Lk✓ Date <br /> EPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:__ <br /> WORK PLAN DATED' CJq� <br /> Application Accepted B Date Issued A+'ea111-- <br /> Grout Inspection By -�' Date g Z9. 0 Final Inspection By Data <br /> Destruction Inspection By Date <br /> COMMENTSICONDITIOHSI W lM. T• C _ <br /> ACCOUNTING ONLY: AID# rfi r <br /> PECOOES FEEINFO AMOUNTREmiTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 9.01 19)_ - 5: 070'�' y5 t sR 0'37988 <br /> C-57 WCC WAIVER C-57 Letter of Authorixdtion to sign permit_.Encroachment d 7 I/P5/ <br />