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02/26/2003 11:08 2094683433 FIFTH FLOOR PAGE 02 <br /> 0 <br /> �) WELL PERMIT APPLICATION FORM SITE <br /> �nl���l MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> MAR 2 0 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> ENVIRUfdMEfJ i 1EALi i! 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 46"449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 9-1115.3�and ythe Standardg of San Joaquin County Enviro gntal Healfh Dept ent,��� �� /f�� <br /> �iT5 JIG "'Pot* <br /> ( �+d rAb`S�essors <br /> WELL Location "9 uSTON qVe, Cross See ��1 City Zip ? Parcel# <br /> PROPERTYOwner CrTy OF R.(PMJ Address ASDL WI II�^ city, Zip! 57��Phone#�� <br /> C-57 Contractor W&&&M�SDIA C Address=zW- F.adf Sf- Ciryad ip u�t Pnone# 53o fele$-Zkzf <br /> Consultant I Sub Cntr,AW.&ttt Address 1400J.VAhor700 City FUll,101AIn Lio# Phone#7(1/Z7."P 21a99z) <br /> GIS Coordinates:XA X6(,5(Y�.Y Z D 34 . 814,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW W ELL/BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTRUCTION(choose type below) <br /> $SOIL BORING# IS'L—I -r—Z, _ DOVER-BORE <br /> aWELL 4 1 q� .t� 701410,4A <br /> T '` ,QP ESSURE GROUT <br /> *Other: Grout Specifications: /YIeEd t!(r� [01410, 4L]r'1C . <br /> COMMENTS Xlt101fA4?JDI' ' r bt O 1dDta Sl1it/Ct(GCI M444 1 Q4 Lc SGOrM��wer. ^ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?6 YES ONO WELL CASING DIA:_ <br /> a EXTRACTION 1]AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING' O STEEL p PVC U OTHER: <br /> 1]VAPOR D MUD ROTARY DEPTH OF GROUT SEAL D-ZZU('fD TREMIE TYPE TO BE USED: D AUGERS -AHOSE <br /> a AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: ?j,Yes ���� ��N�o��r(j1(�N�OTE:�OMAXI UM FREE-LpALL DEPTH IS 30') <br /> SOIL BORING aHANO AUGER GROUT SPECIFICATIONS: $Gntvw7�-- /i GA. Ce/✓I t/L"J <br /> D OTHER. OTHER Wr%i G APPROX.BORING DEPTHZ20 0 BOLTED TRAFFIC BOX or STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list speoificatlons here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby certifyFtat I love <br /> this application and that the work will be done in accordance with San Joaquin <br /> County O f all <br /> Ru l and Regulations, and all applicable Califomia State Laws. <br /> Signed x Ttle/compaly 4i P,/,/ t,,��5 /S - <br /> Print Name $ Date / /�s <br /> DEPARTMENT USE ONLY n <br /> SITE MAP IN UNIT IV FILE,ADDRESS: sJ 0 JDA ( 6L I I y O✓1 <br /> WORK PLAN DATED: O cfi IB ;�-60 y <br /> (/y <br /> Apolicafion Accepted By 9 Data issued Area ` <br /> Grout lnspacUon 8y�ir' r ' Date d� Final Inspection By�-�' f !Date q � 6 <br /> Destruction Inspection By LllDate <br /> COMMENTS/CONDITIONS: blef ce^,LeeLfP056,b k 4^m//t. r <br /> ACCOUNTINGONLY: AID# cni^n <br /> PECODE$ FEEINFO AMOUNTREMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> a416 ( ? %R# 33 <br /> C-57 -- WC---WAIVER- C-57 Letter of Authorization to sign permit,_Encroachment doc_ 1/25/02 <br />