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06/03;''2004 03: 17 209463014,: FIFTH FLOOP PAGE 03 <br /> WELL PERMIT APPLICATION FORM LOP & 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 /> Applicatlon Is hereby made to San Joaquin County for apermit 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 /> WELL Location SCUP C.Ovist 41/c Cross Street//ek; 4I/ City C4_16C Zip Parcel# <br /> PROPERTY Owner Pi/,�i�TI6y)���lc�s's Address 566 GC%y/sf xVt City L�il��t�zip Phone# 95e,-5f,51o, <br /> CS7 Contractor Address CityZL_I Zip�A Llc# 23 Phone# <br /> J <br /> Consultant/Sub CWr /Q� Address Zee I�u//fit:✓,,, Pkl.v City/�j,�Lic# Phone# <br /> GIS Coordinates:X Y Township / / S Range /� G% Section 3S <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> ;WELL# W/c 0 PRESSURE GROUT <br /> a'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING a HOLLOW STEM DIA,OF BOREHOLE �o Q MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Z <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS524 kO TYPE OF CASING: p STEEL )tPVC Q OTHER: <br /> 0 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 75 ' TREMIE TYPE TO BE USED: GAUGERS HOSE/PVC <br /> 0 AIR SPARGE)OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ,VYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH" <br /> IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS �P / w/r�9r a <br /> 0 OTHER: Q OTHER �17,r APPROX.60RING DEPTH b`S / U 0 BOLTED TRAFFIC BOX or STOVE PIPE <br /> CONDUCTOR CASING PROPOSED ye-5; (If YES,list sppofications in comment section) <br /> COMMENTS: 12 5-t«% �i / /c/etbo"-1 <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, Rules and Regulations, and all applicable California State Laws. <br /> Signed x % TiUNCompany CIA�lala�,r <br /> PrintName ��t '!«rYi«d Date-6 f <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED; - <br /> Application Accepted By M-49 � Q Date Issued I1 1� Area_9ef-7 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Dam /U <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# 6638807 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/30/0r <br />