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05/02/2005 16: 08 2094683433 FIFTH FLOOR PAGE 02 <br /> RD <br /> EL::: <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> AUG 2005 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENVIRONMENT i1ALTf 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SEWES (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR PROM 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 /> WELL Assessor's <br /> WELL Locationl^+t 1JeVt u� �6 P5 t 'Cfoss Street �tt7 Str,L' Ci Irc'c <br /> tY Zlp`"�3?(, Parcel#_"z�y t 5� -C 1 <br /> PROPERTY OwnerL�j:uo i P ct41 i. 1100 vrCctJ Co. Address i'+o0 ')o"'Lc iss �Tr City G n,,ti c, ,1 zip }<1 Phone# 'i�i - NN-Ft Co <br /> C-57 Contractor (tl N .,tw"Y, t;,,l;�'Wii(Addressltt; tic,' 1'c1r �Znnch� <br /> k Plcc'�CityC, #C1}Zip':62 , Lic#}04 &f- Phoneh(-'jtb)5YS� '�10 <br /> >uite 4^cc' I?,anc6�v <br /> Consultant I Sub Contractor Gtacv., Cc n'�"ftuvt & Inc Address'(&& 60A L'Cale 17 City CUr' � Lic# Phone#(`11b)E'St-9119 <br /> GIS Coordinates:X ,Y Township_Range Section <br /> WORK TO BE PERFORMED: <br /> ,Rf1EW WELL/BORING MPT,GEOPROBE,HYDR.OPtINCH, HAND-AUGER,OTHER-) 17[DESTRUCTION(choose type below) <br /> _jfSOILBORING# i,{ k' ;It✓-it �'t.i6ti L. , n��S 0OVER-13ORE <br /> *Other: <br /> I]WELL# .&PRESSORS GROUT <br /> Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING U HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES Q NO WELL CASING DIA: <br /> I]EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL I)PVC [IOTHER: <br /> D VAPOR, [)MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS Ij HOSE <br /> Q AIR SPARGE I]PUSH POINT GROUT SEAL PUMPED; Q Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL 60RING II HAND AUGER GROUT SPECIFICATIONS: <br /> p OTHER: 0 OTHER APPROX.BORING DEPTH u BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here), <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> I <br /> Signed Q/V'll' J� IiI�U� Title/Company <br /> Print Name '--4 E t M A R L' LAN))o <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: ` <br /> Application Accepted By Date Issued / ( t J� Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITION5: ' UJ ' �( S. - D c+ , c <br /> ACCOUNTING ONLY: AID# 61� w L� �' �' j d7 GU /t.S �,k -0 ( Y d . <br /> rer•� <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BYDATE PERMIT/SERVICE REQUEST# INVOICE <br /> S Rif <br /> C-57 WC -WAIVER C-57 Letter of Authorizat' n o sign permit Encroachment doc 1/25/02 <br />