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10/08/2002 10:47 2094683433 FIFTH FLOOR PAGE 04 <br /> • <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 /> Appllcatlon is hereby made to San Joaquin Canty 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 the Standards of San Joaquln County Environmental Health Department <br /> Assessors <br /> WELL Location trA APA+b ' Cross StreeiTGM4raC4 Df. CityLac .' 71p ILEO Parcel# 4D4S- 300- 6 <br /> PROPERTY Omegy MIA J. VjtC ler lC.nS Addressl�705. Scor:,„„r.,4n SI City QdL Zi(�Z JPhoneie)L )III36 <br /> C-57ContractorTr.Rernh�iYC..mit V.rc.nAddress�2C0 �cclt(-rc� Cit nzp�OtNO Lic# Phonei� )4S7-$30D <br /> Consultant!Sub Cntr Address City Licit Phone# <br /> GIS Coordinales X .Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OYHER•) n DESTRUCTION (choose type below) <br /> n SOIL BORING# 0 OVER-BORE DIAMETER <br /> n WELL# n PRESSURE GROUT <br /> Other SnI k V&,ear L�or.nbi GROUT SPECIFICATIONS <br /> COMM TS. Sr,.l VG.prr &"r1 PT�' rl <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS NLA <br /> n MONITORING n HOLLOW STEM DIA,OF BOREHOLE 2 n MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA'N/T- <br /> 0 EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS&_TYPE OF CASING_ n STEEL n PVC n OTHER: MIA_ <br /> n VAPOR n MUD ROTARY DEPTH OF GROUT SEAL:-kAk &Rjh TREMIE TYPE TO BE USED: n AUGERS n HOSE <br /> n AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: n Yes []No (NOTE: MAXIMUM FRE&FALL DEPTH IS 30') <br /> n SOIL BORING a HAND AUGER GROUT SPECIFICATIONS NC.&4C eme O'I <br /> ',OTHER:Sb,i Vry ren OTHER APPROX BORING DEPTH 10 &eA n BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: ' <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 dinances, Rules an egulations,and all applicable California State Laws. I <br /> Signed Gf Title/Comparry Qrfs ifl ,nIfC.LtoC f� , <br /> Print Name G Date �O�/'d�oz <br /> DEPARTMENT USE ONLY (Z <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted BY. Date Issued <br /> 3rout Inspection By Data /! t7 7- Final Inspection By Date <br /> Destruction Inspection By Date <br /> :OMMENTS I CONDITIONS: <br /> ACCOUNTINGONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED I CHECK# REC'D BY III DATE PERMIT t SERVICE REOUEST# INVOICE j <br /> d-'F'01 4- gS - x`646 144-- 1012f oz SR# 06 31&6 2 <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />