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09/27/2004 10: 55 209468300^ FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT 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 with San <br /> Joaquin County Development Title,Chapter 9-1115,3 and the Standards of San Joaquin County Environmental Health Department. <br /> �ry Assessors <br /> WELL Location / /G Vis?/ Cross Street City Ca7Li e� ZIp Parcel <br /> PROPERTY Owner ✓.R J/iorl,Gt/of Address/6 777I�tvland �?a�. City 4D Zip Phone>r <br /> C-57Contra ctor'ello.24'9/ Address CityZa.,Zip Lim Phone# <br /> Consultant/Sub Cntr IriP14 Address2oZ Cityj lbc�/on Lic# Phone# 'F193—Ce/0 <br /> GIS Coordinates:X ,Y ,Township T/ S Range.e6E Section <br /> WORK TO 13E PERFORMED: <br /> Q NEW WELL/ BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) []DESTRUCTION (choose type below) <br /> Q SOIL BORING# Q OVER-BORE, DIAMETER <br /> SWELL## POVZ— J�O $PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS_ <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING U HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> - <br /> a EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL Q PVC U OTHER: <br /> Q VAPOR. U MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: - Q AUGERS 0 HOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') —= <br /> 0 SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, <br /> Rules and Regulations, and all applicable California/State Laws. <br /> Signed x %¢sem✓/ T�L Title/Company G bs�es- - <br /> Print Name /7./o Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADD ESS; <br /> WORK PLAN DATED: 7� 0 G�IZ�✓fOt L <br /> Application Accepted By akAllailce Date Issued lU//��y Area 992 <br /> Grout Inspection By ` Date Flnal Inspection Dy Date <br /> Destruction Inspection By LRAADate D 2 t7 C t <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACS <br /> PE CODES FEE INFOAMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> as 02 (00 foo- 3�2 o SR# c),3 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/30/02 <br />