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JAN-10-1999 11:19A FROM: TP,1 2094683433 P:2/2- <br /> WELL PERMIT APPLICATION FORM SITE <br /> JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (209)468-3449 - Fax(�,,oi)A&-.W33 <br /> IR ISSUED <br /> APPIkedon is hm*made to San Joaquin County for a 60 oolts6vd and/or Instau the work dewoed. 1'hi$applica rl is mado In ap,nPrwmWth San <br /> ' D�volopmer>t Ti iO,D OI044r�15.3>A Standards of San Joaquin Cotmty Environmental Hoalth Oepartnwt. 011-0`10-62 <br /> WELL Lotatton 4620 6 ./M a Aa qi a Asslassors <br /> fq J41. N X49 ate, �crossStreet a/.opea�DGE C;f„_Ar/^py z�P bio Paroo601 40-090-3s <br /> PROPEPTY 1-ht�l�.! pow yGrLty?.,-,r1- <br /> OW,W s Address �o me-r% R� Woa�•� ri AOGZ <br /> Phono# ,1 <br /> City Zip _ ^A t, <br /> C47C0ntrac6or 64fter OQ.k-w,sG dress so -C IZLU Ch Mnon�. 21 4VS5 # CIZS 3t • <br /> £df Y P 3 P 3 Shoo <br /> Consultant I Sub cnv•A k go4ece- ,-e•# '„ 4 CIriA.&.y.&?_ucax C 2 I'L t v Ptme�t o 823 I S(o <br /> GIS Coordirot".X Y Township N Ranee -7 IF Section 31 <br /> VNEW WELL,/BORING (1cP GEOPR09E,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (chaise typo below) <br /> 0 SOIL BORING 0 <br /> D WELL# Q OVER-BORE. <br /> GROUT <br /> COMMENfi TS:TS: LAMEETER <br /> 'Other C3ROUT SPECIFICATIONS <br /> TYPE OF WELL MTALL ATION TYPE =NMMUCTIO SPECIFICAT QNS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BORE�IOLE <br /> 4-6 es east !]MULTIPLE CASINGS 0MULTI-LEVEL. WELL CASING DIA <br /> 11 EXTRACTION 0 AIR HAMMERIORIVEN CASING THICKNESS TYPE OF CASING; 0 STEEL 0 PVC 0 OTHER: <br /> p VAPOR p MUD ROTARY DEPTH OF GROUT SEAL&d &j _TREMIE rYPE TO BE USED: p AUGERS 11 HOSE <br /> 0 AIR SPARING OZONE kPUSM POINT(GP or CPT)GROUT SEAL PUMPED: �'es 0 No (NOTE: MAMMUM FREE-FALL DEPTH 13 30') <br /> SOIL BORING Gp r 0 HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER p OTHER APPROX BARING DEPTH GO kgs 5 0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> COMMENTSL CONDUCTOR CASING PROPOSED (if YES,list spocificatiau I n comrnent section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordinances,Rules and Regulation$,and all applicable California State Laws. <br /> SOW � THlacorr`Pony��5—r- " eB m Re Sif Arc <br /> Pratt Ndrrre Date l O-?- -p <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPkWjon Accepted By `G ` <br /> Dam lowed `Arm <br /> Grout Inspecti0r,By at Inspection By Date — <br /> DeWuMon mon By <br /> O� <br /> COMNFxTS 1 CofomoNa: Dan's 1 o rl + Ab �o <br /> ACCOUNTING ONLY: AID# ° `` S�S s kS FAGMza FF7. as 4S-f'2 <br /> PE CODES FEE INFO AMOUNT REMMO CHECKS C' S DATE PERMIT I SERVICE REQMT S INVOICE <br /> o f B 00 2 10 7 qg V05103 sR# <br /> C-57 WC-WAIVER_ C-57 Letter of Autho tzatio sign pe mit Encroachment docs 9/30/02 <br /> _ I <br />