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02.11'. 03/2003 14:35 <br />I�E�i VE0 <br />FEB 2 n 2003 <br />ENVIRUNIViEia I I-iEALTH <br />PERMIT/SERVICES <br />2094683433 <br />FIFTH FLOOR <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL, HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468.3449 <br />PAGE Lit <br />SITE <br />MITIGATION <br />UNIT IV <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 />WELL Location '/ 7 C /y� yt f Cross Street. y� L -v, fjj Assessor; <br />( City c h ZIP Parcel# C <br />PROPERTY Owner �"/).'G1 Yt �' � k Addeess_ <br />` / ) � <br />C-57 Contractor '1/DO�k/a/c✓ �t /!! Address Cit f0 V,S� Zj '"1 n _ <br />�n / / / � P. _Lic# j 00 Phone# iG7 ,)� <br />Consultant /Sub Cntr V/< o! Address �Q ltzr,lf�;,v 0r Py Cid Q Lic# <br />Phone# 1. %/0� �� 'e2CJvO <br />• Y a <br />9 Sec <br />GIS Coordinates: X <br />,Township Ran <br />Section <br />WORK TO BE PERFORMED - <br />0 NEW WELL / BORING (CPT, GEOPROBE. HYDROPUNCH, HAND -AUGER, OTHER") DESTRUCTION <br />a SOIL BORING # p (choose type below) <br />WELL # !) ; i. (�1_ Q OVER -BORE. DIAMETER <br />*Other 0 PRESSURE GROUT <br />COMMENTS: GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CQNSTRUCTI_QN SPECIFICATIONS <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE <br />[] EXTRACTION 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA' � <br />p VAPOR 0 AIR HAMMER/DRIVEN CASING THICKNESS�_6L6�_ TYPE OF CASING. 0 STEEL 11 PVC 0 OTHER: <br />0 MUD ROTARY DEPTH OF GROUT SEAL 1 c7 TREMIE TYPE TO BE USED; AUGERS 0 HOSE <br />AIR SPARGE! OZONE [] PUSH POINT {GP or CPT) GROUT SEAL PUMPED: <br />SOIL BO^!NG p Yes <br />11 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />I] HAND AUGER GROUT SPECIFICATIONS ,il�ar C e -,I <br />fj OTHER:_0 OTHER APPROX. BORING DEPTH C'y BOLTED TRAFFIC BOX or <br />[] STOVE PIPE <br />CONDUCTOR CASING PROPOSED %�=, (it YES, list specificam <br />tions in comment section) <br />COMMENTS: "pL <br />NOTE: O FSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACH E T HERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />county Ordi nce , Rule and Regul "ons, and all applicable California State Laws. <br />igned x r Title/Company <br />'rint NamerC'An • / <br />DEPARTMENT USE ONLY ate /G <br />'ITE MAP IN UNIT IV FILE, ADDRESS: <br />VORK PLAN DATED: -F,)l ✓fin t)'GY� <br />pplication Accepted By�IL41�6 <br />Dat® Issuetl_ <br />rout Inspection By �i Area �b�' <br />Ddb Final Inspection By Date <br />Inspectlon By Date <br />DMMENTS / CONDMONS:__,Z__da - S,)Et <br />ACCOUNTING ONLY. I AID# <br />FAC# <br />U' -r) t't �Y65 t <br />'E CODES FEE INFO�AAMIOI�UNTREM�FTTEDj CHECK # RECD BY DATE PERMIT /SERVICE REQU ST J! INVOICE <br />�ol� 63 SR# pp 3 �it�4 <br />57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit Enc doc 9/30/02 <br />