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FILE COPY <br /> [REC"LEVIE10 WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY J� MITIGATION <br /> APR 2 6 2004 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA! 95202 UNIT IV <br /> I HEALTH <br /> E_P 'TTIWICES (209) 468-3449 <br /> ___1 ___ - - <br /> NON-REFUNDABLE PERMIT EXPIRES I 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 /> - Assessors <br /> C' Zip `�5 <br /> Wrl-l-Locatm 15(o),5 Tm s�f Cross Street L City La+'k 330 Parcel# I <br /> PROPERTY - <br /> -b <br /> owner 3am ii. LaI Addnessj58'.)0 S. 44&r%A, &?3.1 City LI11III!ip%T-3- Phone#9�- Lf <br /> C-57 Contractor <br /> CA 3"Ji- _JE,`Ik� Address3[03Z Ome- Cr City�,* Zip <br /> jd571nUc#_7a5/D_Phone#%6-63?-/j( j <br /> Consultant/Sub Cntr Ajucrceh <br /> i <br /> Ge!aEAv:r0 Address 937 SIII City <br /> Licit <br /> _ _80-VPhone# <br /> GIS Coordinates:X .,y_,Township Range Section <br /> WORK TO BE PERFORMED: <br /> )LNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) GDESTRUCTION (choose type below) <br /> 0 SOIL BORING* I I a bVER-BORE. DIAMETER_ <br /> 7,WELL* MW-00 OPRESSUREGROUT , I <br /> a-0 or GROUT SPECIFICATIONS <br /> COMMENITS� rnove.Al veil or C;4-4e Con s4ryrh;o- 9ro'ec+ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> PCNITORING 0610LLOW STEM DIA.OF BOREHOLE <br /> MULTIPLE CASINGS a MULTI-LEVEL WELL CASING CIA: 2 <br /> a EXTRACTION a AIR HAMMEFUDRIVEN CASING THICKNESS TYPE OF CASING: [ISTEEL CKPI BOTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL /8 TRII'MIE TYPE TO BE USED: flAUGERS 1]HOSE <br /> a AIR SPI OZONE g PUSH POINT(GP or CPT'GROUT SEAL PUMPED: 0 Yes 0,No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING [I HAND AUGER- GROUT SPECIFICATIONS ?or+)an& �? Ceme^+ <br /> U OTHER:�]]01 APPROX.BORING DEPTH 3O. ' :WCLTED TRAFFIC BOX or a STOVEPIPE <br /> CONDUCTOR CASING PROPOSED AI (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. <br /> I hereby certify I have prep a s application and that the work will be done in accordance with San Joaquin <br /> �f d thil <br /> County a s, and all applicable a ornia S e1aws. <br /> Signedx <br /> Tille/Companylkateir � or­ Ahu,,�J <br /> Pdnf Na r 1,I 111,— 9 , Date 4-j- 26-0"I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: �L _7i2__o <br /> Application Accepted By Date Issued D Area <br /> Grout Inspection By Dale Final Inspection By �n 300 <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACS <br /> INVOICE <br /> 4 <br /> PE CODES FEE INFO AMOUNTREMITTED CHECK# RECO BY DATE PERMIT/SERVICE REQUEST# INVOI E <br /> tR% <br /> SRO_0571-1 I <br /> T-r-b <br /> -WAIVER-- C-57 Letter of Authorization to sign permit_✓ Encroachment doc— <br /> 9/30/02 <br /> 141411 <br />