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03/26/2003 16:25 209468343" FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> 04 FER I I AM %4ARONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-9EFt1NDA13LE PERMIT EXPIRES 1 YEAR FROM DATE I$S�ID <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 /> JoaquinCQunty Davelp mant Title,Chapter 9-1115.3 and the tandarde of San Joaquin County Environmental Health Department. <br /> l G,8 E t a l�ek.�dnfl to C St�:wr. , _P. L o-v,, hs AA^ x n c!D ,+�J-ten (Z.g�c� Assessors <br /> WELL Location Cross Street City ZipParcel# 1`k\- 0 50- O <br /> G`nN• �v.r) N 6 w.�.lnn SW db <br /> \-,Q 04r-\W-V. <br /> PROPERTY w e LL ow N E(t '15 N•W: cJr Lo x�e. 2 Q`14-t}08 I <br /> Owner Address 3 9 Clry We xu,� (To�kZip9�1599 Phone#C9 5) <br /> A �:v.J.a *F 2 0 p fan k s 6%k <br /> C-57 Contractor l�o.k .� 9�tYs a Ex • Address P•o•6o x (o ri"1 City g Zip CA <br /> - <br /> Consultant/SubCntrCK-2M \-1\LL Address tS5 GXD-,&PCve. CityOo�k�� a_Lic# Phone#�t��583-,5g� <br /> toao Ate; Rr�e�a Mtk10 <br /> GIs Coordinates:X Y Township Range section <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") DESTRUCTION (choose pe blow) <br /> Q SOIL BORING# p OVER-BORE. DIAMETER ;Z r <br /> a WELL# Q PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS; <br /> TYPE OF WELL INSTALLATIQN TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING Q HOLLOW STEM DIA_OF BOREHOLE__�f Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA; <br /> EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESSTYPE OF CASING: Q STEEL Wf`vC []OTHER: <br /> U VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 4-..&65 TREMIE TYPE TO BE USED: S4UG ERS Q HOSE <br /> []AIR SPARGE/OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED' d Yes 046—(NOTE: MAXIMUM FREE-PALL DEPTH IS 30') <br /> U SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER;_O OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROP08ED /110 (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 INSPECTION& <br /> hereby certify that 1 hav repared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances R s and -rations,and all applicable California State Laws. <br /> ////� <br /> Signed x Title/Company /`�:5- <br /> Print Name �/ ��1� / �✓�/l_(��y __pate Z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted.Ey C. "v Date Issued �T,Area _ <br /> Grout inspection By Date Final Inspection By Date <br /> Destruction Inspection By Data <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY' AID#/ FAG# <br /> PE CODES FEE INFO AMOUNT`REMITTED CHECK# REC'D BY DATE PERMIT SERVICE REQUEST# INVOICE <br /> Z� <br /> &O- CO �� Z IZ v�f SR# 3 6 2� //-7�9S <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authori ti o sign permit,,,,,,„Encroachment cloc— 9/30/02 <br />