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.,.. 27/2004 14 28 2054683433 FIFTH FLOOR PAGE 03 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ON 2'0 2301 ENVIRONMENTAL HEALTH DEPARTMENT (EII UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA , 95202 <br /> NVIRONMti� 1 1 H (209) 468-3449 <br /> PERMII'ISE�.,,_o <br /> ICON-REFUNDABLt=PERMIT EXPIRES I YEAR FROM DAT£ISSUED <br /> gpplicabon is hereby made to San Joaquin County for a permit to construct and/or install the work described This appliratlon 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 /> r n <br /> Assess <br /> ors <br /> S o <br /> S'6 <br /> l3( ca �" Coss StreetCityr 'o-t z.PA ParCelff 30-6P <br /> g <br /> WELL Location Q <br /> �e 3o � <br /> Ez` ro- Ell S 4-�Cs <br /> PROPERTY Own(3 ddress <br /> C-S7 Contractorr <br /> ddrcss�5G� r• C1ty�P4�3L4c#r�`a�Phone# � '� <br /> ! RG Phone#L� 43S­ta5a <br /> Consultant/Sub Cntr_�-o.*•'1�LS r�0. _Address�� per~k'^.s ����C�'���-L�� <br /> GIS Cao►dmaies Jl/ Y Township___ML_N 4Rang��o n! ..Q SeCtao �s4 <br /> WORK TO BE PERFORM MFIJ - <br /> )ZNEW WELL/ BORING (CPT,GEOP ROSE,HYDROPUNCH,HAND-AUGER OTHER-} ]DESTRUCTION e type below) - <br /> ❑SOIL BORING 7i ❑OVER-BORE DIAMETIAMETER <br /> �-� ( ❑PRESSURE GROUT <br /> WELL# / <br /> GROUT SPECIFICATIONS <br /> d'Other <br /> COMMENT'S <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTI0 I SPECIFICATIONS <br /> MONITORING ),HOLLOW STEM DIA OF BOREHOLE I o" ❑M01-7PLE CASINGS Q MULTI-LEVEL WELL CASING DIA f' <br /> ❑EXTRACTION [ AIR HAMMERlDAIVEN CASING THICKNES%:S l- o TYPE OF CASING Q STEEL ;$,PVC p OTHER <br /> W <br /> POR ❑MUD ROTARY DEPTH OF GROUT SEAL =O/ _TFIEMIE TYPETO BE USED ;;AUGERS Q HOSE <br /> SPARGE)OZONE []PUSH POINT(GP or CPT)GROUT SEAL PUMPEDes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATION S$ f n^d �aO�TR�X or Q STOVEPIPE <br /> 1]OTHER OTHER ._._ APPROX BORING DEPTH <br /> CONDUCTOR CASING PROPOSED_ d0 (ri YES,list specifications in commend section) <br /> COMMENTS r O�' r a <br /> NOTE: OFFSITE B RINGS REQUIRE ACCESS AGR EMENT OR EN ROACHMENT PERMITS, <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done Int accordance with San Joaquin <br /> County Ordinance , les and Regulations, ant!all applicable California State Laws- ��Ir <br /> Signed <br /> Trtlejcompany d <br /> Pant Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADD ES <br /> r: -3 <br /> WORK PIAN DATED: I in 1 3 O <br /> Application Accepted By Date Issue_AL1 b="`~a <br /> Grout Inspection By <br /> Date Final fnspecnon By Dale <br /> Destruction Inspection By Data <br /> COMMENTS!CONDITIONS <br /> ACCOUNTING ONLY AID# FACl1 <br /> E CODES FEE INFO AMOUNT REMITTED CHECK tf REC'D BY D TE PERINIT!SERVICE REQUEST tR INVOICE <br /> ESQ <br /> C-57 WC -WAIVER C-57 Letter of Authorization to Sig permit Encroachment doc 9/30102 <br />