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07/03/2003 16 53 2094683433 FIFTH F!_COR PAGE 02 <br /> _ WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> j u N 1 8 2003 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> -'JNMEiVT HEAL74 s <br /> (209) 468-3449 <br /> r VIIT�SE��lCES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appllcaton is hereby made to San Joaquin County for a permit 10 construct and/or Install the work described This appgcahon 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 <br /> rAssessors <br /> yc7Y WELL Location Cross StreetAC", p 9Z o Parce* N�A <br /> PROPERTY Owne <br /> ,_ ddresa S �. . >d, City �c p S Phone* 7�q "25� <br /> G57 Contractor G ) r-� /� ddress �� `!�{� C{1y 4, tp?.t�Ljc# 9`SI1S Phone+Il zcs <br /> ++ `j 3S1r'S5o <br /> ?.mac Qcr-K 1S 54 oty Leo#RS"611- Phone# <br /> Consultant/Sub Cnt��� r i dress rtT <br /> GIS Coordinates X Y ,Township Range Section <br /> WORKCTO BE PE_RE!gRMED <br /> ANEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION (Choose type below) <br /> 1)SOIL BORING# []OVER-BORE DLAMEfER - <br /> *'WELL# ❑PRESSURE GROUT <br /> 0,Other GROUT SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> JcMONITORING jyM0LLOW STEM DIA OF BOREHOL�r� ❑MULTIPLE CASINGS [I MULTI-LEVEL WELL CASING DIA z <br /> j]EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING p STEEL PVC p OTHER <br /> POR ❑MUD ROTARY DEPTH OF GROUT SEAL—n:y Cl/ TREMIE TYPE TO BE USED AUGERS ❑HOSE <br /> SPARGE)OZONE ❑PUSH P01NY(GP or CPT)GROUT 5EAL PUMPED Yos p No (NOTE- MAXIMUM FREE-FALL DEPTH IS 30') <br /> t ` <br /> ❑ IL BORING ❑HAND AUGER GROUT SPECIFICATIONS �C r`� ` •+� 1'+--)Q11`f <br /> []OTHER. I)OTHE APPROX BORING DEPT 6-G � �BpLTED TRAFFIC BOX or I]STOVE PIPE <br /> CONDUCTOR CASING PROPO D Na (If YES,list specifications in comment section) <br /> COMMENTS —c 5e.S�s a <br /> NOTE: OFFSITE BORINGS REQUIRE ACC SS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that 1 have prepared this application and that the work will be done to accordance with San Joaquln <br /> County Ordinances, Rules and Regulations,and all applicable Cahfornla State Laws {� <br /> Title/Compan <br /> SignedySQ'�•or S-r ?� ��✓I '� <br /> Pant Name T'^ n' Dare S' o <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Date <br /> LtS <br /> Application Aocepted By <br /> 1 / ale Issued, f_rL re <br /> Grout Inspection By ate Final Inspection By Date <br /> Destruction inspection By Date <br /> COMMENTS!CONDITIONS <br /> ACCOUNTING ONLY A0# FAC# <br /> CODES FEE INFO AMOUNT REMnTED CHECK q RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> g , OD 3 SR <br /> C-57 Wl -WAIVER C-57 Mer of Auth ,2 I to sign permit Encroachment doc 9/30/02 <br /> r� <br />