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n97/15/2002 13:01 209468343"3 FIFTH FLOOR, PAGE 03 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUfN 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 Tide,Chapter 9-1115.3 and the Standaru�Is o&San JoagJuln County Environmen I He tth Departmant_ <br /> ( �j�✓�h ' `<o& <br /> �V✓l�(��( 15 e� ! y�� sessors <br /> GI/6LL1 OCatiert -�1; l 1 Y' L 1 Cross Atreet II ,,-- City Zip Parcal# <br /> PROPERTY Owner' fY5 L /` Address 5�,0 LA- Cit ZIp�Phoned# <br /> C-57 Contractor � Address �-V �� Ci � 2i Lic# 0 � hpne. R'' <br /> r <br /> Consultant 1 Sub Contracto c7 I01 Address . 5 j l city.���� 1 Lic#�39 Phono#�d �L� <br /> 313 Coordinates;X ,Y Township aN Range q t Section <br /> WORK TO BE PERFORMED: <br /> $NEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH, ND-AUGER THER-) Q DESTRUCTION(choose type below) <br /> $SOIL BORING# l U 0 OVER-BORE <br /> i]WELL# () Q PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS o ' <br /> 1 MONITORING Q HOLLOW STEM DIA.OF BOREHOLE I MULTIPLE CASINGS?Q YES )kNO WELL CASING DIk Y <br /> EXTRACTION Q AIR HAMMERIORIVEN CASINGTHICKNESS TYPE OF CASING= Q STEEL a PVC 0 OTHER: <br /> I]VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL v �O TREMIE TYPE TO BE USED: Q AUGERS HOSE <br /> AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: j]Yes j] o (NOTE: MA{-XIMUM FREE-FALL EPTH 30'} <br /> SOIL BORING 'HAND AUGER GROUT SPECIFICATIONS: < 4 I S <br /> ]OTHER: Q OTHER APPROX BORING DEPTH�Q p BOLTED TRA IC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? specifications YES,list here): T" <br /> 'COMMENTS: <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 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 TrtlelCompany v r <br /> - at (�a� <br /> not Name a- <br /> De <br /> DEPARTMENT USE ONLY {- <br /> SITE MAP IN UNIT IV FILE ADDRESS: <br /> NORK PLAN DATED: c •Z Z Do�� <br /> application Accepted By 6tk,� (late l3sued-06'2-- Area s,_ <br /> gout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> -OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AlD# cer�r <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMrr I SERVICE REQUEST# INVOICE <br /> �'--7567 n— 316.7 � z- SRoao 1 <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc� 1/25/02 <br />