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09/30/2004 10 45 2094683433 FIFTH FLOOR, PAGE 04 <br /> A <br /> WELL-PERMIT APPLICATION FURM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 344 E Weber, Third Floor, Stockton, CA , 95242 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT 1=XP[RES 1 YEAR FRgM PATE'!SUD <br /> Application is hereby made to San Joagwri County fora permit to construct and/or install the work described This appiicat�on is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115 3 and the Standards of San Joaquin County Environmen.al Health 0epartmert <br /> Assessofs <br /> WELL Location s VU ��`� L j'%e Ea Cross Street ewe o C,ty 7-f pL Zp `[ �� Parcel=,_ <br /> PROPERTYQwner i +� Pr�'duc*�� Adr�dress <br /> 7-&j q.7 S �volvn+ i-b cty_Cd+ cn�C Zip gq�Phone# SSS S-�30� <br /> C-57 Contractor lire Address -I tT 4—, City l��k11beZ Zip` ��iLic# N8 I hone# �S { � Ob <br /> Rant.a <br /> Consultant 1 Sub Cntr`a�' o `1rnaf ianc�Address 3cf"] K (fie _ fid, l ,ty �n zloJi_Llc# � �._Phone# l a�4�q �?��� <br /> GIS Cocu,�irnates X YTownship ,So v+h Range S E-at Section ! <br />' NE TO BE PERFORMED <br /> NEW WELL 1 BORING rrrYr --t~OPFZC76E HYD'dOPV^!CH 1-1ANQ AUGER OTHER`} Q DESTRUCTION (Cnoose type below} <br /> SOIL BORING m __ []OVER-SORE DIArnETER <br /> .WELL# /AW- MW= [}PRI-S$UREGROUT <br /> a*Other GROUT SPECIFICATIONS,...._„ <br /> COMMENTS <br />' TYPE 4F WELL INSTALLATION TYPE CONSTRUCTION SPEC151CATIONS +1 <br /> *MONITORING XHCLLOW$TEh1-M*-U OIA OF RDREHOLE_ af 0 MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA <br /> p EXTRACTION [IAIR HAMMERIORiVEN CASING THICKNESS Se- ,y TYPE OF CASING [l STCEL VPVC tI OTHEIR <br /> [1 VAPOR 0 h1U0 ROTARY DEPTH 07 GROUT SEAL TREMIE TYPE TO BE USED AUGERS 11 H055- <br /> AIR <br /> OSEAIR SPARGE!OZONE PUSH POINT{GQ or .,PT GROUT SEAL PUMPED []Yes XNa (NOTE MAXIMUM FREE-FALL DEPTH 15 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS_ _71— <br /> []OTHER_n OTHER APPROX BOPING DEPTH _1'' _XBOfwTED TRAFFIC BOAC or STOVE FIFE <br /> CONDUCTOR CASING PROMO$E[ t�A (if YES,list specifications in camment section) <br /> COMMENTS <br /> NOTE' OFFSITE BORING$ REQUIRE ACCESS AGREEMENT OR ENCROACH <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 Ordinances, Rules and Regulations, and all applicable California State Laws <br /> Signed x 'f tie/Company p'i eC F I."_c'<o i - S to Co;rg <br /> Print Nam Da•e <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS, A ?,- 60 C .. <br />' WORK PLAN DATED. l l O <br /> Applwat�on Accepted Sy Date issued ' E' d Area �� <br /> Grout Inspection i3y Date Final[nspecban By Date <br /> Destruction Inspection By Date <br /> COMMENTS!CONp17iONs <br /> ACCOUNTING ONLY AID# FAC# <br /> PE CODES F1=S INFO AMOUNT RVIMITTF-D CHECK# REG D BY <br /> DATE PERMIT 1 SERVICE REQUEST# INVOICE- <br /> _3 ? <br /> C-57 WC -WAIVER—, C-57 Letter of Authorization to stgn permit. EncrocchMiCnt dac <br /> I <br />