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04/05/2003 13:14 PAX FIdgotOPY <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) 468.3449 <br /> NON-REFUNDABLE PGRMU EXPIRES 1-YEAR FROM DATE ISSUED <br /> Application is hereby made to San Jeequln County for a permit to wnstructandror inatei the Yrorit described. This applics9*1 it made in Compliance with far <br /> Joaquin County Development Title,Chapter 5.1115.3 and tho Stendards of San Joaquin Coumy Environmental Health Department. <br /> Amaso <br /> WELL,Location /�SSD r�'�fjJ� /. r lh Crow Street-�D1t�0 ) R�CI�,�>OLK i bPJ Zip ��piZ�1"S�P �%Q3'1%2-0 <br /> PROPERTYOwncr�jMS. ARI, 2.5 Addrassl��SO u�l�llii/Pry✓t CItyS%OCKTONZIp Phong#�g9'9$(^ },!' <br /> C57Con treCtorlif�,RK .>RILL/+Vl.Address/4L�. PJry_-_._.-.�.�.qty.�il�+�aP'+��aLIc+�la�o4Pr,«,aaS�2-ISIY <br /> Centulta Sub Cntr_A4g;F AddrestiSQRST Ciyi/ee9t AND LIek Phon T®–ddl-DlDJ <br /> DIS Coo dins es:x r �Township /N Range 9E" sec n 11 <br /> FI <br /> E _ <br /> ;�OW <br /> _ P -AUGER,OTHER") DDESTRUCTION {choose type bslow)(CPT,GEOPROBE,HYDROPUNCH,HAND <br /> ,SOIL BORING# Z DOVER-BORE. DIAMETER <br /> D WELL* D PRESSURE GROUT <br /> 0-Othm GROUT SPECIFICATIONS A/eAT CcA44gA/i <br /> COMMENTS.21h t�Sr4MM.F A )V..P srl?A-N ,U }70RENQiE- <br /> TYPE OF WELL (NSTALLATION TYPE CsONSTR!CTION SPECIFICATIONS <br /> D MONITORING $HOLLOW 57EM DIA.OF BOREHOLE_ D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA;AAONc <br /> U EXTRACTION D AIR HAMMERORIVEN CASING THICKNESS TYPE OF CASING; D STEEL D FVC D OTHER: <br /> II D MUD ROTARY DEPTH of GROUT SEAL. 1.201 TREMIE TYPE TO BE USED: 9AUGER5 K�iOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes 0 No (NOTE: MAXIM UM FREE-FALL DEPTH IS 30') <br /> ,$'BOIL BORING UHAND AUGER GROUTBPECIFICATIONS <br /> D OTHER: n OTHER APPROX.BORING DEPTH aA' G BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED /YO Of YES,fist SpedfaStlons in comment section) <br /> COMMENTS: <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 accordanoe with San Joaquin <br /> County Ordinances, Rules a egulations,and all applicable California State Laws. <br /> Sifnedx `L�—`�s"�,. TiUeJCampanylJ_dCrNEss dey X 10-m t1jI1 Ad1< <br /> Print Name d 4's- Dats -6-o3- <br /> DEPARTMENT UpS(EE ONLY <br /> // <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Applirallon Accepted BY Date Issued_ lS�� Area v"" <br /> Grout Inspecson By Date Final Inspectlon By Dote <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AIDre - FA* <br /> PE CODES FEE INFO AMOUNT Rrimn TED CHECK RECD BY I DATE PERMIT f SERVICE REQUEST 4 INVOICE <br /> 2YoI 01 19cc 8IS SR# p /,' <br /> C-57X,- WC -WAIVER„, C-57 Letter of Authorization to sign permit_ Encroo[hmant doc 9/30/02 <br />