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07/30/2002 10:21 2094683 FIFTH FLOOR PAGE 03 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 466.3449 <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. <br /> f_Ak (Vo (-Di/L 9P4-1'T7&OKwo In14 I Assessors <br /> WELL Location 01-jxle a(=L{0 nloz;r+/4,41N ST CrvssStreet E(-M ST-, City I.Ob1 Zip 52Y-0 Parcet#(c(LEA)1121GyF-cf l4/,ay <br /> � � -T��� Sir,(i /D <br /> PROPERTY Own <br /> 1er ` 1" ,.L/ff2l/ ENI,S Address 2L-S3 N 4_YXI-t/0.5 City `�iipcK7w Zip 5207 Phone# (209)'+77-3533 <br /> C-57 Contractor L.AYntE(ri21ST&QSE?Ua, Address 110D( CTI POMAVE, City on7 to Zip 233 Llc#SIoDI Phone#(g09 3�0-21133 <br /> onsultanf Sub Contractor E2C 9EMEDiA770,q LLC Address530o4✓eo0my2EbR EtDLc#Phone#(W)�31-(v%GYo <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ` ,NEW WELL!BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER-) a DESTRUCTION(choose"a below) <br /> 0 SOIL BORING# 11 OVER-BORE <br /> AWELLV MyV - T1-fft01,,Gtt M1hi-� �PRESSUREGROUT <br /> 'Othar: Grout Spec fication& <br /> COMMENTS: Iy' t A�vrvU�u� 1t fVE StAj,eD W TTt3'W i�ltctc f'v1 iCr�NITt l��uET st7ti f(flpiZr3iEll�AB�Ctti Q4 P>gCK <br /> TYPE Or WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE ib rAf, MULTIPLE CASINGS?0 YES )(NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER7DRIVEN CASING THICKNESS Z p SCtI.9-0TYPE OF CASING. []STEEL KPVC d OTHER: <br /> U VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL —j- TREMIE TYPE TO BE USED: `(AUGERS a HOSE <br /> 0 AIR SPARGE o PUSH POINT GROUT SEAL PUMPED. a Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 17 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Al"T cfmEh7 L,IT�I 5% ('FENTON tlE l)a✓6ct2 <br /> Q OTHER, 0 OTHER APPROX.BORING DEPTH (D 2-rr, BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? NO _(if YES,list specifications here)- <br /> 'COMMENTS: 604 Sc %yc� �/S 1 (� 1 U1��� C! tvp <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x �Cv 41il.- t TitlelCompany S !O{Z GON-L -(4 C2-C jZemmgnoA/ LLC <br /> Print Name /' <br /> _ r I►3'1�1< yy• CC- by Date IN fl/03 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: ��(�.n -� i�t,�.�_�,� L I IJIZc✓a<'rr <br /> Applicatlon Accepted Byif <br /> Dale Issued �f 7/ aJ Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> C4/`N <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK r1 REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> (2-(Z'-/ � `� `/ �3 S R# <br /> C-57� WC=WAIVER_ C-57 Letter of Authorization to sign permit—Encroachment doc_ 1/25/02 <br />