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07/30/2002 10:21 2094683433 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 descubed. 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 /> 4tM Assessor' <br /> WELL Location �/l(O�'7}l r'l�f� ST/Zl:�r Cross Street ELnn City LoDI Zip9SZ'0 Parcel#'• may <br /> 2 1=wcy; <br /> PROPERTY Owner �PIVESTM�NTS Address2 3G.RRNPCANflLkyolcltySITcI�TDN Zip SZD Phone#'(�)+-77-3'33 <br /> C•STContractoryiRDNEX,ZNC, Address Z) ID/ p,,}ryI5AVeIUC City. A ANP ip q 771-1c# 65 Z7 Phone#(S10S6S-7,6 6 <br /> /��Ml05 <br /> onsultant Sub ContraGor t2L 12tEPIf}77W�,LLC-Adclmss5300 V40 MERCn�Scity ' I:fa.p_ic# Phone# 66/L -bf6,6 31 <br /> GAS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL 1 BORING(CPT,GEOPROBE.HYDROPUNCN,NANp AUG R,OTHE ( typa below) <br /> FOIL BORING# -) I �q n DESTRUCTION choose <br /> I � �FFs l�) <br /> WELL f# ()OVER-BORE <br /> D <br /> r� PRESSURE GROUT <br /> *Other: Grout Specifications- gury'ntf f7E eEI-CC'rS TD 5 FT- Clk WL- <br /> COMMENTS: itelMC)iT C,EmENi To GrZ,OUWP S41ZFOCF- V'iI}TnEYt11E f fP��wirtt 57� <br /> � (',rntluNlfE ('WER ftfro��, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n MONITORING 0 HOLLOW STEM DIA OF BOREHOLE 2-" MULTIPLE CASINGS?DYES �,NO WELL CASING DIA-, <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL n PVC d OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 0 F`i-SO('-1,TREMIE TYPE TO BE USED: <br /> f ps U HOSE <br /> 0 AIR SPARGE PUSH POUJT GROUT SEAL PUMPED: Yes 0 No (NOTE; MAXIMUM FREE-FALL DE TH IS 30') <br /> )(SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: &1W CEZoE97- MT"H G7o ('EA7bu ITE <br /> 0 OTHER.-_a OTHER APPROX.BORING DEPTH ZQ 50 FT n BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? D (if YES,list specifications here): _ <br /> *COMMENTS:— _ p(Astf S01c- f3o,21w S, <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 L%' Title/Company SCN(O(L GiE-aie 1�T -E-2,C "c--O,M�N LLC <br /> Print Name K Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATEDL:J , <br /> Application Accepted By k-144 Date Issued 101Y1,12— Area C(/&21-"4E43 f U l <br /> Grout Inspection ByDate /U.47-11 D 2 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS ICON DITQNS: t� <br /> ACCOUNTING ONLY: AID# <br /> e4�y <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK• REC'D BY DATE PERMIT 13l�RvfcE REQUEST INE <br /> VOIC <br /> aye► Bir 8 ���1 /� /D y bL SR# 0-0-3t c/(/ <br /> C-57' WC_WAIVER_ C-57 Letter of Authorization to sign permit— Encroachment doc_ 1/25/02 <br />