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09/30/2004 10 45 2094683433 FIFTH FLOOR PAGE 03 <br /> WELL-PERMIT APPLICATION F6RM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTW DEPARTMENT (EHD) UNIT IV <br /> ^ 304 E Weber, Third Moor, Stockton, CA., 95202 <br /> (209) 46$-3449 <br /> NON RFTUNDASLE PERMIT EXPIRES i YEAR FRONS DATE ISSUED <br /> I Application is hereby made to San Joaquin County for a permit to construct andlor Install the work described This applicaton Is madro In compliance with San <br /> nstr <br /> Joaquin County Development Title,Chapter 9-1115 3 and the Standards of San Joaquln County Environmental Health DepartmontAssessors <br /> Jae. ipo..Abo X53-7{� Parcel# It' _o2-o17 <br /> WELL Location S-3,-7s. 1N Gruen} LCL hQ PA Gross Street 1� CItym �iG� _zip <br /> I <br /> i Add <br /> ress eyt 4S �,Wti F wi U,9 City_�Ar <br /> PROPERTY Owner I� CJS Zip`�O }D Phone# S� ���-`� � <br /> I`ar'e r-n-S+*-v Addressq_ plc GZtyr�i1 zip �T Lic# Phone# `Zz.s I - 0C <br /> C-S7 CtictraCtor_..� <br /> 4 tv�.._�� ^-- -' <br /> Iconsultant!Sub Cntr�s<CD�. �n�-�'f`t��s'fiitl�dres5 01 �k �� � c� a 4 Lac# f�.S4 �i � <br />{ re ! <br />` GIS Coordinates X,,Y 7own5hip $cuTV, Range t 0.�+ Section <br /> WORK TO BE PERFORMED DESTRUCTION (choose type below) <br /> OEW WELL 1 BORING (CPT,GEOPPOBF HYQROPUHCH,HANQ-AUGER OTHER') � �OVER-BORE DIAMETER <br /> ;.DI4 BORING# []PRESSURE GROUT <br /> n WELL# GROUT SPECIFICATIONS <br /> []'Other <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I [j MONITORING a HOLLOW STEM DIA O�SORRHOLIr-� 0 MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DhA <br /> EXTRACTION p AIP HAMMERIDPIVI=N CASING THJCKNESS_ --7—TYPE OF CASING p STEEL [I PVC a OTHER <br /> VAPOR []MUD ROTARY DEPTH OF GRDUT SEAL RD TREMIE 7YPe TO BE USEQ 9 AUGERS ,(HOSL <br /> I <br /> AIR SPARGE(OZON7 WUSH POINT(GP or CPT) ROUT SEAL PUMPED gYes []No (NOTE MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING p]HAND AUGER GPOUT SPECIFICATIONS <br /> APPROK BORING DEPTH U BOLTED TRAFFIC BOX or ©STOVE PIPE <br /> 0 OTHER O OTHER <br /> I CONDUCTOR CASIN$PROPOSED„_ _(If YFS list Specifications in comment section) <br /> COMMENTS <br /> NOTE OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT FERMI . <br /> d8 WORKING HOURS NOTICE REQUIRED FOR INSPECTIVNS <br /> I hereby certify that I have prepared this appllcatlon and lca that <br /> t e work I fora Sill be done in l ate Laws accordance with San J u+n <br /> County Ordinances, Rules and Regulations,and all app <br /> ( Title/Company i':-o' e C* 6-e—A ;, 1 - C Cl <br /> Signed x <br /> Data <br /> Pnnt Name <br /> IDEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE ADD[tESS- L-S e <br /> D <br /> WORK PLAN QATED' (� <br /> Date IGSUed <br /> Application Accepted ay pate <br /> Grout lnspeGtlon Hy��,� <br /> r G.�-. pate 2 Final Inspection Sy <br /> Derttuction inspection By 02te <br /> GOMMEHTS 1 CONDITIONS <br /> ACCOUNTING ONtY AIDS FRC# <br /> pIr CpDES FEE INFO AMOUNT REMITTED CHECK# RFC'D$Y DATE pF_RMFr I SERVICE REQU>=57 # INVOICE <br /> 12- <br /> 3� P <br /> C_57, W� -WATVER C-57 Letter of Authorkzation to sig permit Encroachment doc� 9/30/02 <br /> I <br />