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NOV 1 9 2003 WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> 'ENVIRONMENT HEALTH ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> PERMIT/SERVICES 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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 /> �I Assessors <br /> WELL Location Z IQ I A1aYy �P iVQ Cross Street 5TOR< City JI0L)C TDPJ Zip �5 206 Parcel# 115-030-09 <br /> OwnnerERTY S-F 5F2"1G Address 2q`1 lJAyr [)e(y1 City STA Mtj Zip'JJI�'ZaoPhone# Z 5- Z Z 8"32L7 <br /> C-57 ContractorSPt'•G'I?�UM FYpl�ddress2 6l+�Gw� D[%vE Cit��y//55d (. l>j Zip�S Lic#S122b8 Phone# yl� IZ <br /> Consultant/Sub Cntr NACI CROwWP Address fJ CBNTERPOINTB �7Ccity�AJ01��ie4tLic# Phone#503 foZO us 4 <br /> 1 O' <br /> GIS Coordinates:X 3Z 5(0' 2l f1 -'Y-1Z1 ZC) 0 <br /> 1i Township �r" Range Section O <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> I SOIL BORING# 12- 0 OVER-BORE. DIAMETER <br /> WELL# l ( 0 PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE)0 $ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION Z 0 AIR-HAMMER/DRIVEN CASING THICKNESS%114ID 4 0 TYPE OF CASING: 0 STEEL I PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 10-2-o FT TREMIE TYPE TO BE USED: N AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS OC-A-V GeMEWE <br /> 0 <br /> OTHER:_O OTHER APPROX.BORING DEPTH I3 - 25 t=T q BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED /Un _(if YES,list specifications in comment section) <br /> COMMENTS: `t INCL1 WELL " I D 1t60e'ae OLE Z 1"LN W£3/i�5 gJ2E4-iGI.E 13 Frweu=l(2Fr(Aamfr L'7 =�& <br /> NOTE: OFFSITE BORINGS REQUIRE 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 San Joaquin <br /> County OrdinancRules:andegulations, and all applicable California State Laws. <br /> Signed x Title/CompanyA�uAT5 kircl, / ZooS�Print Name <br /> G-15N Date !v O✓ 3� Z � <br /> DEPARTMENT'USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDR SS: <br /> WORK PLAN DATED: <br /> Application Accepted Byy' --Q� � Date Issued 42-(! 3 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date Qk <br /> COMMENTS/CONDITIONS: B1 44 eZ 5 1 P-5 A 40-61 &)(1 y S 1- P -' " S' <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �O �� "' 9 3. 5 SR# 3�2() 5 <br /> C-57_ WCWAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br /> = <br />