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10/08/2002 10:47 2094683433 FIFTH FLOUR 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 PERMrr 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 the Standards of San Joaquin County Environmental Health Department <br /> Assessors <br /> WELL Location %bAP S�%U -;4"6iA+a <4 Cross Slreettr&wr_6cit br. City LOA, XP am-2,40 Parcel# <br /> PROPERTY Owne&rald J. Vi Cdtr)CAS Address\320 S. Sc,Crhmt A S1 City ),Derr ZiprjS_2 JPhana7 6)L;)UZ 2-456 <br /> C57ContradorMC&erah',1C _rrlV,ranAddressL2CQtYrnLtAf-r LL. �. Ci rs Zip4ktV40 ick Phones LE )101 -I-3300 <br /> Consultant/Sub Cntr Address City Oc# Phone# <br /> GIS Coordinates X Y .Township Range Section <br /> WORK TO BE PERFORMEDt <br /> n NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') n DESTRUCTION (choose type below) <br /> n SOIL BORING# a OVERBORE. DIAMETER <br /> n WELL# a PRESSURE GROUT <br /> Other Sei Vt.Aar �r,n� GR99T SPECIRICyTONS <br /> COMMENTS: ) Vlr hONnti Zia (25ec &t4cc.l'Pc{ �i vre- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n MONITORING n HOLLOW STEM DIA.OF BOREHOLE-2 n MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA:WA <br /> n EXTRACTION n AIR HAMMERIDRIVEN CASING THICKNESS_ TYPE OF CASING n STEEL n PVC MOTHER: NtA— <br /> a VAPOR n MUD ROTARY DEPTH OF GROUT SEALTak,I dtpli'I TREMIE TYPE TO BE USED: n AUGERS n HOSE <br /> 0 AIR SPARGE/OZONE []PUSH POINT(GP or CPT)GROUT SEAL PUMPED: n Yes n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> n SOIL BORING n HAND AUGER GROUT SPECIFICATIONS # re mP ni <br /> AOTHER:C*.�iyoWr D OTHER APPROX.BORING DEPTH 10 (re zF n BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) N <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 43 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and ReaLilati ns,and all applicable California State Laws, <br /> Signed Title/Company ProdC-CA bif-C_CJ-iC--�r /T2C- <br /> PrintName S Date to/1q,101— <br /> .9 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> QPPlicationAccepted By J ,�.e-� _ Date Issued rfJ�2S��L- q,e�lll2L✓l1C Oma{ <br /> 3rout Inspection By, u Date / -2- Final Inspection By Date / <br /> Destruction Inspection By Data <br /> COMMENTS!CONDMONS: <br /> ACCOUNTINGONLY: AID# - FAC# <br /> PE CODES FEE INFO AMOUNT REMrrTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST0, INVOICE <br /> a 101g5 Oq1 6 /U vz SR#D o <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />