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05/02/2005 16: 08 2094683433 FIFTH FLOOR PAGE 02 <br /> 1° �� () ,/� WELL PERMIT APPLICATION FORM <br /> utvl �� SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> n� © r; _005 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENVIRONVENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SEROCES (209) 4683449 <br /> NON-REFUNDABLE PERMrT 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 wi San <br /> Joaquin County Development Title,Chapter 9.1115.3 and the Standards of San Joaquin County Environmental Health Department. p b 0(' 01 <br /> Bo r vv / '7�.Q, Ave, Assessors <br /> VKf Lop tion 5 fih S�Q Cross Street(tai e, City �1 aC Zip % Parcel# L3 S-I!;-1 <br /> Ca II`` P. L811 l > I1el� <br /> PROPERTY OwnerUn;t cn 16i 'r r!,L 1��(rock C' Tess l oo L vA AS S+ a City Omctt7 e� 1Jt Zi Phone# yOZ S y�'��Dh <br /> C-57 ContractorV t Y O h�i Z r LIC.!C. Address Z t l O A jGI vn C A/Q G <br /> _City e c <br /> L� "jvv Zip`t'/5}'4 Lic#-foqzT Phone# S r o� z p-}6 <br /> Consultant ubContractor`ae-CCnn lCi>Iltlfahtb ,L1r.Addres9316v c � Untft IZGt h chu'0i'. CityC�,_CgLic# Phone# RI0PiS2- X11/$ <br /> GIS Coordinates:0-i NL4 (� III c 75 3s"�J S 2i 2 6cc _ <br /> t <br /> 1 ,Y ,Townships Range 5 Section z <br /> WORK TO BE PE MED: <br /> d NEW WELL/ ORIN (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) D DESTRUCTION(Choose type below) <br /> XSOILBORING#_ _� ,�;r�cZ- �Ush bo-11'-JS DOVER-BORE <br /> 11 WELL# D PRESSURE GROUT <br /> `Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING 0 HOLLOW STEM DIA,OF BOREHOLE MULTIPLE CASINGS?DYES ONO WELL CASING DIA: <br /> 0 EXTRACTION D AIR HAMMEFUDRIVEN CASING THICKNESS TYPE OF CASING: U STEEL V PVC U OTHER: <br /> O VAPOR o MUD ROTARY DEPTH OF GROUT SEAL I TREMIE TYPE TO BE USED: U AUGERS U HOSE <br /> U AIR SPARGE XPUSH POINT GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> D SOIL BORING 9 HAND AUGER GROUT SPECIFICATIONS: NB6 � �� �icj�y-[p !l6dLr"s 6 PWY 1 <br /> I]OTHER: D OTHER APPROX.BORING DEPTH p 60LTED TkAFFIC 60X or <br /> U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: N,0 Lvc,k - Soil 14,-, ljrhGi <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 I have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordinances, Rules and Reg I tions, and all applicable California State Laws, <br /> Signed xM1. T7tle/Company<'L9JJioV- STp1 F 6 D IS17 CEt) ]? <br /> Print Name GtM M,4 �, 4B LA tJ DO � o <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS; <br /> WORK PLAN DATED: /+ /� <br /> Application Accepted By^�,�} , ���� Date Issued �Arod <br /> C <br /> Grout Inspection 6y J ---Date Final Inspection 0 14 Date, -7 •� <br /> Destruction Inspection By _ nates , <br /> COMMENTS/CONDrriONS: PAy-LFI Vrc-vie r Fro 'r a <br /> 14 j <br /> ACCOUNTING ONLY: AID 5 U t ?ti - 1` ctI + �,) APO <br /> enr-e <br /> #3 7 35 15-00 ' <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2 L) 0 �; • �v 5Q5 6 '�. 5 .fi SRS Z? 0 <br /> C-57 WC -WAIVER C-57 Letter of Authori�atior sign permit Encroachment doc_ 1/25/02 <br />