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b0/bL/21JUb ib: UH 2094683e FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM <br /> SITE <br /> 4U 3SAN JOAQUIN COUNTY MITIGATION <br /> 2005 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENVIRDIW�ENT _ 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PER'AV"T/SER+,iI�ALTH <br /> ES (209) 4683449 <br /> Application is hereby made to San Joaquin <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> County for a permit to Construct and/or install the work described. This application is made In compiiance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> WELL Location {n rY" e- Cross Street Ce'GI G'� City Assessor's <br /> I'G,C Zlp �Is3}G <br /> PROPERTY Owner Un opt PUParcel# Z3p-ls�- I(„ <br /> Cifi�, ci;lr e:i (.o , Address op�c c 5 SFreett <br /> City ern, zip.Gg 1}�/ Phone# t1c2-5`f4-BbeO <br /> C-57 Contractor TNci�hern(�+I fbf,A i•�vAddress_i 13 50 M c:� t-� <br /> ✓ purk f lac_Citykowcl o �r jp y yLLic �oL-sb�Phone# 61/6)90-goio <br /> onsuli Sub Contractor Ada Cc tis,Itcar� Tn site gco. <br /> �s c- Address 3i c Gold ✓'II e D r; Ciry M �rash <br /> Phone7�l°I <br /> GIS Coordinates:X ,Y Township Range <br /> _Section <br /> WORK TO 8E PERFORMED: 9 <br /> EW'WELL/BORING(CPT GEOPROBE YDROPUNCH,HAND- UGER,OTHER-) <br /> )rSOIL BORING DE5TRUCTION(Choose type below) <br /> UWELL# 11 RE <br /> Z'PRE SUORE GROUT <br /> 'Other: <br /> COMGrout Specifications: cen 4- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICgT10NS <br /> 13 MONITORING 0 HOLLOW STEM DIA,OF BOREHOLE <br /> p EXTRACTION MULTIPLE CASINGS?[]YES ONO WELL CASING DIA: <br /> Q AIR HAMMERIDRIVEN CASING THICKNESS _ <br /> VAPORTYPE OF CASING; Q STEEL Q PVC Q OTHER: <br /> . Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED; D AUGERS —QHOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED; Q yes 11 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: <br /> Q OTHER: Q OTHER APPROX BORING DEPTH _Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> 'COMMENTS: CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS 1N ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done In accordance with San Joaquin <br /> County rdinances Rul and Regula ions, and all applicable California State Laws, <br /> I <br /> Signed Title/Company GCZCoV� CpnSUitcvttS <br /> Print Name SEM MA P.C$L A N U Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted Byto Issued ZJed <br /> Grout Inspection By Date Fnal Inspection By. i Date <br /> Destruction inspection By Date <br /> COMMENTS/CONDITIONS: bz,ZO Wi P- <br /> ACCOUNTING ONLY: AID# W 0 J1� �y� �nr� C✓� Z✓I ^�7 c �rc1c <br /> rr <br /> PE CODES T FEE INFO AMOUNT REMITTED CHECK It RECID Py DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2�� .oG OSI 3 ��G sR# `f <br /> C-57 WC -WAIVER C-57 Letter of Authd�izatio� o sign permit Encroachment doc 1/25/02 <br />