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05/03/2002 13:09 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHO) �I ` " 'Yl P_y <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> N_ON.REFUNDABLE PERMIT EXPIRES 1 YEAR FROM GATE ISSUED <br /> Application is hereby made to Sen 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 Tide,Chapter 9.1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> HELL Location z p(7 l W cam.i t! Cross Street Y.. /1Vi- City �TO L ICj7}Al/ip (5 ZV LI Parcel#Assessor's <br /> C/o 3=i2C-vkl- <br /> sROPERTYOwner NiCf rcri-F... �ur�sr :vt iddreSs Y arc+ /([� Q Git}MrAw�- G2k, p 7VAPhonet <br /> :37 Contractor CAddress N'T � City CzfI 4?_t <br /> r 21 <br /> : Address � �0 /f �� A's. <br /> city "1 [ic# Phone# <br /> 3IS Coorddinates.X 10 6510839 E ,Y /%2G tIG�6/� ,Township 1 Z N Ranged;/= Section 3 S <br /> ,VAI, 1_1� <br /> YORK TO BE PERFORMED: - <br /> tdQ�W WELL!BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) /7iDESTRUCTION(choose type below) <br /> -\ <br /> I]SOIL BORING# LIPI — tlP '?L !/_ _ DOVER-BORE <br /> 1 <br /> Il WELL# t> 2EESSURE GROUT <br /> Other. Grout Specifications: r —1 , <br /> :OMMENTS; <br /> YPE OF WELL INSTAL1AT10N TYPE CONSTRUCTION SPECIFICATIONS <br /> I MONITORING a HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?DYES I]NO WELL CASING DIX--- <br /> I EXTRACTION - (I AIR HAMMER/DRIVEN CASING THICKNESS— TTYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: 0411- <br /> I VAPOR `Il MUD ROTARY DEPTH OF GROUT SEAL /p n%O TREMIE TYPE TO BE USED: p AUGERS ? {OSE <br /> J AIR SPARGE 18KL15H POINT - GROUT SEAL PUMPED; s p No (NOTE: M MUM FREE-FALL DEPTH 1155 30') <br /> j�OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: C 7K E7,)T "TrTt� Ijt <br /> OTHER: a OTHER APPROX.BORING DEPTH -S.S , I7 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> / p CONDUCTOR CASING <br /> /PfPPOSED? (if YES,list specification are), <br /> :OMMENTS• a""L' /wr vN[c(:1 i7¢ i-lir �(r..T W /.v •. /Y'7'N r'J z - �� Y�7 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby _ertify.tha �re�pfepared this application and that the work will be done in accordance with San Joaquin <br /> :ounty Or i'nance'- I s and egulations, and all applicable California State Laws. / /-� <br /> iy0ed x �!I TitlelCompany� i 1 IZ -0 '�+<r 5 z- V <br /> dnt Neme / NIK <br /> � Date Z <br /> DEPARTMENT USE ONLY <br /> ITE MAP IN UNIT IV FILE, A DRE7SS: <br /> IORK PLAN DATED; y/ , /O 2 <br /> opllcation Accepted By .Date Issued <br /> � _l5—/Zd�Z Area <br /> rout Inspection By C)` Date-L IF l Inspection Bye—� Date <br /> estruction Inspection By Dat <br /> OMMENTS I CONDITIONS: 5 <br /> ACCOUNTING ONLY: AID# <br /> Knrx <br /> ?E CODES FEE INFO AMOUNT REMITTED CHECK S RECD BY DATE 'rRMTr I SERVICE REQUEST# INVOICE <br /> 3Rt1 17 <br /> :-57__ WC=WAIVER_ C-57 Letter of Authorization to sign permits Encroachment doci, 1/25/02 <br />