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10/13/2003 10 46 2094683433 FIFTH FLOOR PAGE 02 <br /> •��� <br /> L '�WWELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY <br /> VIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT A <br /> 0MITIGATION <br /> 4 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDAPLE PERMIT EXPIRES 1 YEAR FROM DATE tS UEp <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 9-1915 3 and the Standards of San Joaquin County Environmental Health Department.Assessors <br /> WELL Location Z bC) west I!'a ro,vr� �-i A2 ra56 Street�e orr+bO ity Lpt Zip 4.5��Parcel# 38�00-a l <br /> PROPERTY I <br /> pIS��Phone <br /> owner �.ne Addres # <br /> b'3z Dr'e- _ Gi f _CiR <br /> ty odova Zlpl( L42L1o# sI0 Phone#-(l � (i i4 <br /> C�7'ContractorCa$���. �i`�r�i Address _ <br /> Consultant!Sub Cntr S�GdR r,n IeCrti43'iona�,ddress`3 � kti�� � C1ty ^d�A Liu#GGS��R$ Phone# alb Bbl-OgCa <br /> GIS Coordinates X-„ Y ,Township_ _-S Range —SoctlQn <br /> WORK T!2 HE PERFORMED_ <br /> NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") p DESTRUCTION (cito4se type belaw) <br /> SOIL BORING#k 1)OVER-BORE DIAMETER <br /> WELL# MW-1 �t1ui�ouSLti i'h�"�' c .�cow �� Q PRESSURE GROUT <br /> 'Other <br /> GROUT SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WELL INSTALLAMON_TYP1E CONS C710A1 SPEC/FIGATIONS �! <br /> MONITORING 'HOLLOW STEM DIA OF BOREHOLE R_ 11 MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING❑1A �+ <br /> 1]EXTRACTION 17 AIR KAMMERIDRIVEN CASING THICKNESS LAO TYPE OF CASING A,STEEL X PVC I7 OTHER <br /> TI VAPOR o MUD ROTARY DEPTH OF GROUT SEAL, 3 TREMIE TYPE TO BE USED )CAUGERS p HOSE <br /> SPARGOZONE 1]PUSH POINT(GP or CPT)GROUT SEAL PUMPED d Yes )(No (NOTE MAXIMUM! FREE-FALL.DEPTH IS 30') <br /> IWSOILR E!BORING 11 HAND AUGER GROUT SPECIFICATIONS <br /> p OTHER.. 11 OTHER APPROX BORING DEPTH ` AW-16 OLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications In comment secteon) <br /> COMMENTS /hW-b =�Sfi - rel�a� 6"/clic. Gw1c1uG{Dr GASi 10 -dor 7rou4 5��1 iS v <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHhIIENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I herby certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin <br /> County Ordinances$ Rules and Regulations and all applicable California State Laws <br /> Signed x �� �TitlelCampany ` a+ Geo/ i 5'3- SG_Loi� �,n�erna iertA <br /> Print Name ►� DEPARTMENT USE ONLY Date I <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: 1 v3 <br /> Application Aumpted By a-, Date Issued L-04 11&- -S —_ Area_ <br /> Grout Inspection 8y bate_ Final iri$pecttan By Date <br /> Destructlan Inspection By Date <br /> COMMENTS!CONDMON8 <br /> ;ACCiOUNTING ONLY AID# FAC#! <br /> FEE INFO =AMOLINTEMITTER CHECK# REC"D 8Y DATE PERMIT!SERVICE RECtUEST# INVOICE <br /> OD <br /> (Of 0,3 SR# <br /> C-57 <br /> 9�30�02 <br /> WC_-WAIVER_ C-57 Letter of AuthorlZatlon to Sign pe.rmit�Encroachment doc <br />