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01/03/2003 14. 18 2e9468M-133 FIFTH FLOOR w PAGE e2 <br /> .,:-WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNITIV <br /> 1 8 20M <br /> FL- 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468,3449 <br /> NOR-REFUNDABLE PERMIT EXPIRES I YEAR r-Rom PATE ISSUED <br /> h <br /> Application is hereby ma'do to San Joaquin county for a permit to construct andlor Install the work described. This application Is made in compliance with San <br /> Joaquin County Developmenl.Tide,Chapter 9-1115.S and the Standards of San Joaquin County Environmental Ha2lth DepartmenL Assessors <br /> WELL Location Cross Str"tAW-)0tjAUT- City'3'roc—Y-To r-4 Zip 95202 Parcel# 1(o'. 2(o007 <br /> ?.d-0--A 1.2 55(o <br /> PROPERTY Own L) <br /> Address 302 0,Tkar,* Av6—city EAC-INC>AC -7-3�10 <br /> 12AWCQO <br /> OA46C Cityr <br /> C-57Contractor C A c6±T)S 09,AtnLAO'z�- Address3l(42 =29-4WA Zjp1574j2_Ljc0_jl7510 Phone#­(4-1�a <br /> X03 -!I(o9 <br /> Consultant/Sub Cntr 7,E OTaJ>,r,'-1, `NC. Address302115 city ­.C9fttvs�3-t R� <br /> C#3YPhonep <br /> 99—0 <br /> - <br /> GIS CoordInates:X_,Y-----,Township Range lu 6 section Nofje: Qi\jetj <br /> WORK TO BE PERFORMED' KAND-AUGER,OTHER*) XID%SCITRUCTION (choose DIAMETctype <br /> ONEW WELL/ BORING (CPT,GEOpROGE,HYDROPUNCH. <br /> SOIL BORING# n <br /> 11 RESSURE GROUT <br /> QWELL# GROUT SPECIFICATIONS NE-AT CF-MEN4r <br /> 0*Other -3S' SGS Nr-4r� AUGEoes- <br /> COMMENTS: p(Z.-eoae-_tA\tj <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING C HOLLOW STEM DIA.OF ROPEHOLE_ []MULTIPLE CASINGS 91MULTI-LEVEL WELL CASING DIA; <br /> _ <br /> 11 EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS_TYPE OF CASING: QSTEEL OPVC 11 OTHER; <br /> 1]VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TPEMIE TYPE TO SE USED: OAUGERS a HOSE <br /> a AIR SPARGE!OZONE 0 RUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> U SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> OTHER;_1]OTHER_ APPROX.BORING DEPTH_0 BOLTED TRAFFIC SOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED_(if yE$,list specifications in comment section) <br /> COMMENTS- EEMENT OR ENCROACHMENT PERMITS. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGR <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 Ordi noes, Rules and Regulations, and all applicable California State Laws. -I <br /> Signed x ---Ttlelr-ompany5E�-" �C-7 �( <sf �66Ta s <br /> Print Name KEtTy-�- kf'�/ Foal 04—_> DEPARTMENT USE ONLYDate�_�' <br /> SITE MAP IN UNIT IV FILE, A=R :ES� Alit rli' <br /> S <br /> WORK PLAN DATED: <br /> -;Z�—ILL,—3Area- 12 <br /> Application Accepted By Date Issued—1-/1 61 <br /> Grout Inspe c1lon By L) Date Final Inspection By —Dalo <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACIE <br /> P <br /> I FEE INFO AMOUNT REMITTED CHECKO PERMIT I SER=E REQUEST# INVOICE <br /> PE CODES RECD BY DATE <br /> 3S 1 jz4-7 zl 43 SR# 3 ;0 <br /> C-57_ WC -WAIVEP— C-57 Letter of Authorization to Sign permit_Encroachment doc 9/30/02 <br />