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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 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,,,�`r <br /> WELL Location IiZ9- 13� S Su"ZitheAlu Sf . Cross StreetT[uwarncit_ 6r. City Lodi zipli-4t/o Parcel# L 4sst - .�G�--II <br /> PROPERTY Ovmer�Ne4,.; .-O Ik0�'2 Ser•AddressllLC7 S. 54Crc,MC4:jaCity L do Zio57YO phone# <br /> C-57 ConhactorTrAaA024aX, TaUrr, Address(47 P[tt�. CityLoS Anfzdn ZipfC0L4CLic# Phone# �ItS'7 'J3� <br /> Consultant/Sub Cntr Address_!Bi S G.,v.^erl al (salty.C.umCorCl Oc# Phone#(92S)('$8-I bO�- <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> )rNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> p SOIL BORING# 0 OVERBORE. DIAMETER <br /> n WELL# 0 PRESSURE GROUT <br /> %*Other iZ.00r 6,,r.n4S GROUTSPECIPICATIONS <br /> COMMENTS: V4;i\ \kAph2r� S 10? (3 (5" u-M'C' 5,}P oro�� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING n HOLLOW STEM DIA.OF BOREHOLF_ 0 MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA: uIh <br /> 0 EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS t.I/P TYPE OF CASING 0 STEEL flPVC n OTHER: 13/A <br /> 0 VAPOR n MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS II HOSE —� <br /> a AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes Po (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> n SOIL BORING n HAND AUGER GROUT SPECIFICATIONS 4 <br /> ) OTHER: f a OTHER APPROX.BORING DEPTH n BOLTED TRAFFIC BOX w 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) V <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. 0 <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 a <br /> County Or4utanees, Rules and Regulat' s,and all applicable California State Laws, ¢ <br /> Signed G Title/Company �(aa&Cii11Dlfleiz1 c� r <br /> Print Name M Y Date <br /> DEPARTMENT USE ONLY <br /> e <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: �j Q <br /> appL�1'c�nr��Clication Accepted By , Date Issued <br /> 3rout Impaction By.���<- Date 1?/� UD- Final Inspection By Date <br /> Destruction Inspection By Date <br /> :OMMENTS/CONDITIONS: <br /> ACCOUNTINGONLY: AID# - FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> (^ /� /ozs oz SRO Qo g 6 s9 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />