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01/27/2004 14 28 2094683433 FIFTH FLOOR PAGE 02 <br /> ,i <br /> no Cc- <br /> WELL PERMIT APPLICATION FORM SITE <br /> C SAN JOAQUIN COUNTY MITIGATION <br /> -" ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> JAN <br /> 2 0 2904 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENTNCALTH (209) 468-3449 <br /> PERMIT/SERVICES <br /> �r7r Erj'Vf CE5` NQN-REFUNpABLE PERMIT EMPIRES'I YEAR FRO BATE ISSU7~D <br /> kpphcabon 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 /> loaquin County Development Title Chapter 9-1115 3 and the Standards of San JoaquFn County Environmental Health DepartimmentASBeSsars <br /> �r-i A '1tac _ zp�^Parcelos2 `�—jj <br /> HELL Location Z p c c�c- . Cross Street 4Y J City_,_, <br /> PROPERTY Owner ma Q cv ddress Com-` A Clrys'��i� � Z1P?--Phone#?-��4s I-� `� 1 <br /> G57 Contractor r-: L�_ Address9 CltY22-,4 ^=�- zP` -L' g5 Phonsl►SZ�'31�` <br /> Consultant 1 Sub Cntr �-✓+�r"'0. ddress -2 P�r�r 5-" 4City LIct Phone�t_ 'S' <br /> n1 A Y N 4 , r� <br /> GISCoordinates Township � <br /> WOR TO BE PERFORMED <br /> -gNEW WELL/BORING (CPT,GEOPROBE HYDROPUNCH HAND-AUGER OTHER`) 0 D�SOTRUR BOON DIAMETER Type below) <br /> 0 SOIL BORING A 0 PRESSURE GROUT <br /> ZWELL9 ^tL,3 -12— <br /> GROUT SPECIFICATIONS <br /> 0.Other <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Z r/ <br /> )WONITORING ;j HOLLOW STEM DIA.OF BOFtEHOLE fi�r+ ��0 cMULTIPLE CASINGS 0 AAULTI LirV Et WELL CASING DW <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS S���'PV-OF CASING a STEEL PVC ll OTHER <br /> 0 POR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 'AUGERS 0 HOSE <br /> R SPARGE/OZONE 0 PUSH POINT(GP or CPI GROUT SEAL PUMPED ;a Yes p No <br /> (NOTE, MAXIMUM FIRE -FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONLI <br /> TI <br /> [J OTHER _[1 OTHER. APPROX BORING DEPT ❑BOLTED TRAFFIC BOX or a STOVE PIPE <br /> ONDUCT R CASING PF10PO5ED o (if YES,list specifications in comment section) <br /> COMMENTS �GGL �130G <br /> NOTE. OFFSITREQUIRE 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 will be done In accordance with Sart Joaquin <br /> County Ordinances Rules wd Regulations,and all applicable Callfornla State Laws. <br /> Signed Tole/Company <br /> DsI�1 -t-Id SI <br /> Pnnt Namo <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, A DRESS: <br /> WORK PLAN DATED' 3 <br /> Appiic;.tion Accepted fay <br /> Date Issued d Tea Zf <br /> Grout Inspection By <br /> Date Final Inspection By74 Date <br /> Deslruct,on Inspection Py_ Date <br /> COMMENTS I CONDITIONS <br /> CCOUNTING ONLY AID# FAC# <br /> E CODES FEE INFO AMOUNT REMITTED CHECK# REC'D L3Y DATE PERMIT SERVICE REQUINVOICE <br /> EST# <br /> SR# 3 <br /> hment doc 4f3Df02 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit 1=ncraac <br />