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67/03/2663 16 53 2094683433 <br /> FIFTH FLOOR PAGE 04 <br /> WELL PERMIT APPLICATION FORM SITE <br /> �� �� �� ��1Uf SAN JOAQUIN COUNTY } MITIGATION <br /> FF- ENVIRONMENTAL HEALTH DEPARTMENT EHD <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> JUN 1 8 2003 (209) 468-3449 <br /> 1_jW1RLjN1 LN r HEALI H NOWIREFUNDABLE PERPArr EXPIRES i YEAR FROM DATE ISSUED <br /> ippticaborRg f �E,Wi�;Joaquin County for a permtl to construct and/or install the work described This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115 Sand the Standards of San Joaquin County Environmental Health Deparment <br /> WELL Location Street ,c cs- City,- ff r/ P_____`L_._� / <br /> PFIOPF14TY OwnB f •rnr�- -1 _Afddress C' Z04M CZ04ity c�F�Yon_ Z+p Sz�f P!►one#C 52 3656 <br /> 0-57Contractoxg L=' /S Address c Cgy!ter-4; p4Phona X25 3t3-SSoo <br /> Consultant I Sub Cntrr_zkv Lr_�C dress C N 1rr"AS S�. City�Ltc#IR --f> Phone#L�� <br /> GIS Coordinates X , Y ,Township Fangs Sectro <br /> WORK TO Sl;PEL9FORMED _ <br /> ,KNEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER") Q DESTRUCTION (choose type below) <br /> 0 ML BORING 1" (Z OVER-BORE DIAMETER <br /> 4W ELL#-_ ML--�s +�.?-q - U PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS <br /> TYPE_OF WELL INSTA_LLATI.ON_TYPE_ CON$TRUC710N SPECIFICATIONS <br /> ;9MONITORING AHOLLOW STEM DIA OF 5OREHOLE !9:/ [I MULTIPLE CASINGS I]MULTI-LEVEL WELL CASING DIA Z�� <br /> �]EXTRACTION {i AIR t-tAMMERIDRIVEN CASING THICKNESS ;5--Lq O _TYPE OF CASING Q STEEL fl:?VC J]OTHER <br /> Won U MUD ROTARY DEPTH 0l=GROUT SEAL —_1 Q9 TREMIE TYPE TO BE USED $AUGERS HOSE <br /> SPARGE/OZONE 0 PUSH POINT(GP or CP'T)GROUT SEAL PUMPED 1;-Yss a No (NOTE- MAXIMUM FREE-FALL DEPTH IS 30') <br /> (}SOIL BCRING a HAND AUGER GROUT SPECIFICATIONS � <br /> 0 OTHER OTHER APPROX SOF0NG DEPT 6 C>f OLTED TRAFFIC BOX or (]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (it YES,I,st specifications in comment section) <br /> COMMENTS r- cr- <br /> NOTE: OFFSITE BORINGS 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 wifl be dome in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws <br /> Signed T,tia/Compari <br /> Pnnt Name_ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED. <br /> Application Accepted By .- _ _ _. Date issued " _ oo q_Area - - - - <br /> Grout Inspection By Data Final Inspection By Date_ — <br /> Destruction Inspection By Data <br /> COMMENTS f CONDITIONS <br /> ACCOUNTING ONLY AID# FACE <br /> E CODES FEE INFO AMOUNT REMITTED CHECK# RLC D BY DATE PERMiTI SERVICE AF-011,11EST# INVOICE <br /> SR# <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc__ 9/30/02 <br />