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05/02/2005 16:08 2694683433 FIFTH FLOOR PAGE 02 <br /> E�WELL PERMIT APPLICATION FORM <br /> D SITE <br /> AUC; ` SAN JOAQUIN COUNTY MITIGATION <br /> L005 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENI/1RONMENT 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERP41T/SERVICESrH (209) 4683449 <br /> NON-REFUNDABLE PERMIT EXPIRES 9 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 /> WELL Location �� sfrat Cross StreetrQ. Ur4 Assessor's <br /> City El Zlp �:3�, Parcel#_L 36) j�;V- 1(„ <br /> PROPERTY Owner Un opt P64cifiG AddressyoC�cu,j�;s Str <br /> t ezt City�'34Jac� tum zip Llt'rl Phone# bL7175Y'♦-zecC <br /> C-57 Contractor N�rShWn(-',li,f i ,.Address t165 (v1c:1 e, c4' cCityRotaclo <br /> 706-'6 e- Phone# <br /> onsul n Sub Contractor egc�n Cc,%, a gots Inc Address City �n co�Q��)e# PhoneYJlqui)63Z'RI(8 <br /> _._-..� <br /> GIS Coordinates:X -1Y Township_Range _Section <br /> WORK TO RE PERFORMED: <br /> EW VVELL/BORING(CPT _GEOPROBE,+1YDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION(choose type below) <br /> WSOILBORING#'�-ir L;,"�cT �``jlk ""i <br /> (]WELL pOVER-BORE <br /> # 8'PRESSURE GROUT <br /> 'Other: Grout Specification--: - <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA,OF BOREHOLE MULTIPLE CASINGS?[]YES ONO WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL 0 PVC D OTHER: <br /> 0 VAPOR. 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS []HOSE <br /> UAIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes I]No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING U HAND AUGER GROUT SPECIFICATIONS: <br /> 1]OTHER:_0 OTHER APPROX.BORING DEPTH []BOLTED TRAFFIC t30X 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 OrdinancesRulgs and Regulations,and all applicable California State Laws. <br /> Signedx uuv L �/ Title/Company 6ezc� rk Li.u'1il tCot�S Lrlf . <br /> Print Name GEML� A LLLANDO Date 1�� c75 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS. <br /> WORK PLAN DATED' / <br /> Application Accepted By 'cam, n c�. Gti� to Issued 5 /2 � Z C%C�'�._ <br /> Area <br /> Grout Inspection By Date Final Inspectlon By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: `- ( y �� ;r <br /> ACCOUNTING ONLY: AID# (71 O JVD <br /> �er4r 7 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT SERVICE REQUEST# INVOICE <br /> .71 <br /> SRV <br /> C-57 WC -WAIVER C-57 Letter of Authdt^ization to sign permit Encroachment doc 1/25/02 <br />