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. 07/28/2004 15:09 2094683 FIFTH FLOOR • PAGE 03 <br /> 010 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> 'P�VIRONMENTAL HEALTH DEPARTMENT (EHarl UNIT IV <br /> � �c�304 E. Weber,Third Floor, Stockton, CA., 9520! <br /> �' (209) 468-3449 <br /> NON-REFUNDABLE PER rl EXPIRES 1 YEAR F OM DATE ISSUE! <br /> Qrk Is Ilcauon is made in cor tpllance with San <br /> Th <br /> Application is hereby made to San Joaquin County for a permit to construct an&or instat the <br /> Env ronmental Hea th Department. <br /> _ Assesso s <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin , <br /> ' �. tri/,�/ _Zip -)� G Paroel#i_ <br /> Ni Cross Street s — V City _ <br /> WELL Location �'`' _ <br /> �L`�liPhoneif <br /> 7, Z pe. vA _ZiP— <br /> r(fe Address lir) �1 Ci ��1 -4 1L, <br /> PROPERTY Owner u" t �G-77� ,r 7`N hone#� 1✓1'�-3� <br /> y ?7 c.L�c# <br /> j � it Cid '_Zlpyr�-- <br /> i�Scc- ! T Address e �i.I� _ -7 I66 <br /> G7 Contractor ) `,r Citi ic# ���Phona <br /> Ad !J �,s�`�,;,� City`'/� <br /> Consultant/Sut?Cntr dress Section__ <br /> GIS Coordinates:X �Y <br /> ,Township Range___ <br /> WQRK TO BE PE FORMED: DEST RUCTION (choose type below) <br /> ,8'NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") []DESTRUCTION <br /> 0 b�rER-BORE. DIAMETE:_ <br /> SOIL BORING# 0 PIr.ESSURE GROUT <br /> ELL# GROUT SPECIFICATION$ <br /> Qther - <br /> COMMENTS: <br /> TYPE INSTALLATION TYFI= CDNSTRUGTION SPECIFICATIONS <br /> DIA,01=BOREHOLE �% � `U ULTIPLE CASINGS p hIJL71-LEVEL WELL CASING DIA: <br /> AONITORING Z FiOl,LOW STEM TYPE OF CASING: p STEEL PVC [I OTHER:�— <br /> EXTRACTION 0 AIR HAMMER/ CASING THICKNESS �"v�y�' i TREMIE TYF'I TO BE USED: O At GERS �}HOSE <br /> ,8 C/APOR p MUD ROTARY DEPTH OF GROUT SEAL <br /> NO E: MA;UMUM FREE-FAL.I_ DEPTH IS 30') <br /> AIR SPARGE!OZONE d PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ��G�O`NOy(NOTE: <br /> - <br /> 0 SOIL BORING []HAND AUGER GROUT SPECIFICATIONS _G�- <br /> APPROX,BORING pEPTH l 6KT OL7ED TRAFFIC BOX or []STOVE PIPE <br /> []OTHER: —0 OTHER___ i YES,list specifications in comment section) <br /> CONDUCTOR CASING pROPOSED_ , <br /> COMMENTS: ��i j✓ / !) G=v <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACH MENI' PERMITS. <br /> 48 WORKING S. <br /> HOURS NOTICE REQUIRED FOR INSPEC <br /> 1 hereby certify that 1 have prepared this application and <br /> at hCa iforniaork llState Laws,e done l accordance with San Joaquin <br /> County ordinances, Rules and Regulations,and all applicable �C> <br /> ry <br /> 1i p ,. TitlelCompanY _ <br /> Signed x (��i `U ✓ / t,� Date_ l !Z` — <br /> Print Name ��� J J�'i` '�^ � <br /> pEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: r - o LE <br /> U i2 ©- <br /> WORK PLAN DATED: vl(J <br /> i Area <br /> l � �/ � Q Date Issued -, —`--' <br /> Application Accepted By 1�4 t `" �l oat( <br /> Date Final Inspection BY�- <br /> Grout Inspection By Date <br /> Destruction Inspection By t-7 ..:�— <br /> COMMENTS I CONDITIONS:,CL) <br /> ACCOUNTING ONLY: AID# <br /> FAC# - — <br /> pE CODES FEE INFO AMOUNT REMITTED CHECK# REG/'�D BY DATE PERMIT/SERVICE=REQUE,'T# INVOICE <br /> SRIt�, 9/30/02 <br /> d <br /> (C J K— permit—Encroachment doc___ . <br /> C-57— WCC WAIVER C-5�Letter of Authorization to sign <br />