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di <br /> I 09/ 25/ 2002 13 : 16 20946B'gr+ 3,y,,\ FIFTH FLOOR , � PAGE 03 <br /> 111 WELL PERMIT APPLICATION FORM SITE <br /> IF11 <br /> � I� ' G) SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> MAR 1. 8 2004 304 E. Weber, Third Floor, Stockton , CA. , 95202 FILE 1 <br /> ENV! RONIUENT HEALTH (209) 468-3449 <br /> PERM F1 /SE R AGES 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 Tifle, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department- <br /> G44 v ( � P IA R Et I4 G- C A IFJW-F Assessor's <br /> WELL Location 13, G M< livau K S r Cross Street c . BSrt3 � C( �V�Iry STCCt��fG l't Zip � 5t4 '4 Parcel# .-- I3q I2QDZ <br /> aAN 7Vt"ctzklN Cu� i`{ C'( <br /> PROPERTY Owner r`ALiLI IES HQMC- f� EF'i_ Atldressll22s : 5GGjT5 Ccs CiryS'IGCK ( Llti Zipi � LGL Phone# (ZV { ftL ` is F <br /> d 'tc LSY <br /> C-57 Contractor_ dress -`) 5II {' P I 'S pLRGE CItyj ' e-y Zip i-LSk Ltc# 4e ;3QGS Phone#'. (41d +) 11ta3 5 :1r <br /> Consultant / Sub Cr�tr ipt t'1 f; C-h Addross " �; (' � .4 i` ' ClP%A14Ct�ttf- UcORCE1 ;' EE °teQ ' Q <br /> I' . H Phone# � �ui � T' �- v <br /> F- 12cNthcN'F . [ i IIvC -. -utTIET 4 <br /> GIS Coordinates; X , Y . Township Range Section <br /> WORK TO BE PERFORMED: <br /> III NEW WELL I BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) p DESTRUCTION (choose type below) <br /> a $OIL BORING# G ' 41 CT ' s� LC* '" gn aOVER-BORE <br /> U WELL # O PRESSURE GROUT <br /> 'Other: Gmut Specifications: <br /> COMMENTS s3 i ON - SlTf ('a-r0rPiC ( F C4CIitNCS fE9 F ( RSf <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> O MONITORING 0 HOLLOW STEM DIA, OF BOREHOLE ry h MULTIPLE CASINGS? 0 MULTI-LEVEL? p WELL CASING DIA: NA <br /> 0 E)CPRACTION p AIR HAMMER/DRIVEN CASINGTHICKNESSK_ TYPEOFCASING; OSTEEL OPVC UOTHER: NA <br /> U VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TO 7:: `3C I TREMIE TYPE TO BE USED: O AUGERS N HOSE <br /> U AIR SPARGE / ozone ® PUSH POINT GROUT SEAL PUMPED: U Yes N No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> B SOIL BORING O HAND AUGER GROUT SPECIFICATIONS: RENT S -E ME RT <br /> p OTHER: D OTHER APPROX. BORING DEPTH 10 ' 0 BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? I4 O ( if YES, list specifications 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 /> hereby certify that I have prepared this application and that the work Will be done in accordance with San Joaquin <br /> .ounty Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> iignedx 1-�v� Kc2"'•^.^"" Lr Tllle/Company udl�( 5 'vi. TAi'(`I' , t"� AIVtFrGt- FtVil't4' hti�tE1� 'f1lL_ <br /> print Name •.( uA M A C DateI I I � f G � <br /> DEPARTMENT USE ONLY <br /> >ITE MAP IN UNIT IV FILE, ADDRESS : 13e N , H V R 'C IE k $T K E E L S T C C- KTO R C4 <br /> YORK PLAN DATED : M A Ry to lZ p2�(11Z!4j _ <br /> application Accepted,,ByV i A."t"6 r ,i � <br /> t LL �. �, 1 � L4U Date Issued I 2 p0 4 Area 1 4 5_ <br /> ;rout Inspection By <br /> V� f7SUi' i LL MU.OYY'Tl^L.T_Date 3 u Final inspection By ` m Date 14y <br /> —T <br /> testruetion inspection By Date <br /> :OMMENTS / CONDITIONS: A <br /> ACCOUNTING ONLY: AID# nru <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE PERMIT I SERVICE REQUEST #' INVOICE <br /> 350 ( gq, 00 8q0 oo IsR# 00372, 61 <br /> -57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc,_ 8/29 /02 <br />