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11/18/2004 14 24 2094683433 FIFTH FLOOR PAGE 02 <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 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to Sen Joaquin County for a permit 10 construct and/or install the work described This application)s 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 /> WELL Locatlon Assessors <br /> Cross Straet City cC.�,. Zlp, 52aQL,�F'arcel#��_20 t f� <br /> PROPERTY Owner Address �y GtyS�C_'►Z1L �P Phona#�'j (OO L, <br /> C-57 Contractor Address (,=h4fd <br /> '1 Iry�fpg �iCs#ZS. ��Phone Z�{ <br /> Consultant/Sub Crttr � 0QL)nAey-w-�9r�'Adaress_�j' KI'l0P__��' Cit),� <br /> GIS Coordinates X_. !U A Y-- - A Township" AI)a Range-- N.14 ._Sectron <br /> NORK TO BE PERFOR E[7 <br /> O(NEW WELL 1 BORING (CPT GEOPROBE, HYDROPUNGH HAND-AUGER,OTHER-) d DESTRUCTION (choose type below) <br /> 13 SOIL BORING# <br /> WELL#�vr(-t1 MYV-.1 Z� 0 PRESSURE <br /> OUTDIAME=fi <br /> p`other . � - - ,." Q PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> :0MMENTS --- + bas <br /> ME OF WELL INS/ ATIQN TYPE CONSTRUCTION SPECIFICATIONS <br /> KMONITORING tHOLLOW STEM DIA OF BOREHOLE d MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> ]EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASINCs <br /> STEEL ,EPVC 13 OTHER <br /> ]VAPOR 11 MUD ROTARY DEPTH OF GROUT SEA r <br /> tLR _ 'PREMIE TYPE TO 8E VSED ,'I*UGERS a HOSE <br /> WSPARGE/OZONE Q PUSH POINT tGP or CPT)GROUT SEAL PUMPED ;;Yes q No (NOTE MAXIMUM FREE-FALL DEPTH IS 301) <br /> BOR[NG a HAND AUGER GROUT SPECIFICATIONS_nea.+ C_PJY't?A± <br /> ]OTHER p OTHER APPROX BORING DEPTH___?C) `KBOLTED TRAFFIC BOX or a STOVE PIPE <br /> COMMENTS <br /> CONDUCTOR CASING PROPOSED, 14/A (if YES Inst speoficatlons In comment sechon) <br /> _ r 5 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR EN ROACHMENT PERMI S.�-IQS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> hereby certify that I have prepared this application and that the work will be dobe In accordance with San Joaquin <br /> .,ounty Ordinances, Rules and Regulations,and all applicable California State Laws, r� <br /> 3rgned _ T1Ge/Company uc.4 <br /> 'nnt Name C�LSe it Date Q a <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 32 0 Z J, <br /> NORK PLAN DATED: 5 O p <br /> kppirmitlon Accepted sy u i e--+A r:a.- L. b6e-ektincq date tssued-�d dem I d0� Ares_ j 5 q <br /> 3rout Inspeotlon By. Date Final Inspection By Date <br /> )estnrctron Inspection By Date <br /> :OMMENTS!CONDITIONS <br /> ACCOUNTING ONLY AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT SE=RVICE REQUEST# INVOICE <br /> Or 8'q.0,0 89, vo SR# 00 0.epo � <br /> f:`57 WG -WAZVER_ C-57 Letter of Authorizatloh to sign permit Encroachment doc 9/30/02 <br />