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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 /> Application is hereby made to San Joaquin Canty for a permit to construct andlor install the work described. This application is made in compliance with San <br /> Joaquin County DevelopmentTitle,Chapter X1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> } S <br /> Assessors c <br /> WELL Location I bXP Sett^ Sz C,-AA,aAIa S1 cross StreetTG raCic br city Lee`, Xip 2-tgo Parwi#04 '3�`q <br /> PROPERTY Owne&erGld J. Vfnl/r IC_nS Address\320 S. Sc:Crr,mc iib SI City—LQZip z oPhone;tus)('8b-2- 136 <br /> C57 ContractorZrAerph Sit...itV,rcn Address�ZCb l�arlAFrc� Cil rl ZtpgodfO.LidF Phonef�4S-7-$3oD <br /> Consultant/Sub Cntr Address City LEe# Phone# <br /> GIS Coordinates X ,Y .Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPr.GEOPROBE,HYDROPUNCH,HAND-AUGER,OYHER') n DESTRUCTION (choose type below) <br /> n SOIL BORING# 0 OVER-BORE DIAMETER <br /> G WELL# n PRESSURE GROUT <br /> Other So: VnPur 6�r.n4z GROUT SP CIFI TONS <br /> COMM TS: \ Ye po r r.n 23 LYe C�eit ke �vrC.) <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n MONITORING U HOLLOW STEM DIA.OF BOREHOLE;2u n MULTIPLE CASINGS n MULTI-LEVEL WELL CASING <br /> Il EXTRACTION n AIR HAMMERIDRIVEN CASING THICKNESS N M ----TYPE OF CASING: n STEEL n PVC R OTHER <br /> n VAPOR n MUD ROTARY DEPTH OF GROUT SEAL-rofA t depth TREMIE TYPE TO BE USED: n AUGERS n HOSE <br /> H AIR SPARGE!OZONE n PUSH POINT(GP or CPT)GROUT SEAL PUMPED: n Yes n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) W <br /> 11 SOIL BORING n HAND AUGER GROUT SPECIFICATIONS N" re.me of <br /> AOTHER: ;j VWr n OTHER APPROX.BORING DEPTH 10 re ej n BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (it YES,list specifications in comment section) ,n <br /> COMMENTS: ^ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. N <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 Ornances, Rules and Regula '//,, s pnd all applicable California State Laws, <br /> Signed x TiUelCompany bro c,,c� t�t r-c , r /T fc . _ <br /> Print Name Date 10115�(O'L G <br /> DEPARTMENT USE ONLY <br /> s <br /> SITE MAP IN UNIT IV FILE,ADDRESS= <br /> WORK PLAN DATED: Y/ <br /> Qppiication Accepted By Date Issued /�z,� 62 Areae✓t���e IS�CJf <br /> 3roul Inspection By. Date/ 6 D L Final Inspection By Date r <br /> )estruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTINGONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> D( S5 ' G /old D SR# p o 3l 6l0 0 <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment dot_ 9/30/02 <br />