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10/08/2002 10:47 2094683433 FIFTH FLOOR PAGE 04 <br /> WELL•ERMIT APPLICATION F•M 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 andlor install the work descrthed. This application it made in compliance with San <br /> Joaquin County Development Tlde,Chapter 91115.3 and the Standards of San Joaquin County Environmental Health Department <br /> Assessors <br /> WELL Location 1121- 13c9-- S /n1 o S I . Cross SbeetTamar '+CCIVI LCA) X'ip 9S4t1 D Parcel# c5t(s''L90-D <br /> PROPER7YOwnerNFi,�CO WCA2_-Ul_Addressl�Z9 S • S4cuf'-"-cIfD Cily I.00AI Zip �l0 Phones! <br /> C-57 Contractorj-cAc40'Iex_, hA111r. Addreas1 Lcb PCcc.14r Le `�rCityv5An °s Zip- Ct4CIJc# Phone#! 000 4 �T-33 CO-" <br /> Consultant I Sub Cntr L Addresser L r�tlGal C:rCity Lic# Phone#C425�q��120� <br /> GIS Coordinates:X ,Y .Township Range Section <br /> WORK TO BE PERFORMED: <br /> )rNEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') n DESTRUCTION (choose type below) <br /> U SOIL BORING# O OVERBORE. DIAMETER <br /> n WELL# n PRESSURE GROUT <br /> .%*Otherr Imr,nAS GROUT SPECIFICATIONS <br /> COMMENTS: �V 2L Bir,1P 3i 4 t 15-& -7 1% 15'r 161 17 p lig &fp F, -z JrC) <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> U MONITORING U HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS N MULTI-LEVEL WELL CASING DIA IS�, <br /> p EXTRACTION AIR HAMMERIDRIVEN CASING THICKNESS I.l IP TYPE OF CASING, n STEEL p PVC U OTHER: ),J/A <br /> U VAPOR MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS UHOSE <br /> U AIR SPARGFJ OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED: n Yes po (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> (7 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS 11 PA-Fo fnel)4 <br /> )(OTHER:Scr ITU ^OTHER APPROX.BORING DEPTH l0 i G PA U BOLTED TRAFFIC BOX or U 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. 3 <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 an egulations,and all applicable California <br /> State Laws.'t� <br /> Signed x-\Zl a/ /.L.�/ r� Title/Company rCL' I C t.J IrLC�UI <br /> Print Name �1?M P ��`Ff Date (0/Sr✓�2 . <br /> ^- DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: D <br /> 4pplicationAccepted B��� ^�'�� Date Issued �z- Arelei✓ <br /> 3rout Inspection 8y Id�LL+,"'D'(r Date I 6 _L - Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTINGONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK4116 BY DATE PERMIT I SERVICE REQUEST A INVOICE <br /> D/ 84^ B 646 � /D SOz SR# Do3 6S7 <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />