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07/07/2003 11:01 209467111 PAGE @2/03 AGE STOCKTON <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQ(JIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (IEHD) <br />304 E. Weber, Third Floor, Stockton, CA., 9!i202 <br />(209) 468-3449 <br />NON-REFUNDARLE PERM[ E(PIRES 1 YEAR FROM DATE IS31A--.1) <br />Application is hereby made to San Joaquin County for a permit to construct ard/or install the work described. T'ils opplit ation is made In compliance with San <br />JoaquIn County Developatent Title, Chapter 911115.3 and the Standards r)f Snn Jeaguin County Environmental Health E opait-nent. <br />Assessor's <br /> <br />Cross Street /U.( cuy ize -r Zip T_ i:al'4.)-__p.r.ef#, 7 Ttif <br />ec.(k iniAddress qq.n_ oil:Pal/57,yd ione# (;20 (r/3 ) <br />C:1Y.Lft2 ifrAL_ZIPL2S:;7_*_Lica Address <br />co( ova— <br />Address 316, ha 4, holie#_Cji : I cZ..(a <br /> <br />, Townshio Range Section_ <br />11 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HANO-AUGE R, OTHER') <br />Kan BORING # <br />SWELL # <br />COMMENTS <br />WELL LocationiTa&iLaidafal_ <br />PROPERTY Owner <br />C-57 Contraotor4 kk.0-11. Dr 1 <br />Consultant / Sub CntrALLA <br />GUS Coordinates: X <br />WORK TO H E PERFORMED: <br />11 DE STR t.iCTION (nooae. typo below) <br />U OVER-BORE <br />UPRESSURE GROUT Grout Specifications: fr.; f 1-1(1.„L-ol <br />TYPE OF WELL 1NLLATION Typg <br />MONITORING HOLLOW STEM <br />fi EXTRACTION []AIR HAMMER/DRIVEN <br />fJ VAPOR fl MUD ROTARY <br />a AIR SPARGE Ozone u PUSH POINT <br />Its.SOIL BORING ['HAND AUGER <br />BOTHER: 0 OTHER <br />• <br />'COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE_ 52 MULTIPLE CASINGS? U !AULTI-LiEVEL71 WELL CASING DIA:, <br />CASING THICKNESS. ,Sc„Lio _ TYPE OF CASINC-: STF:EL ;11PVC a OTHER: <br />DEPTH OF GROUT SE.4d_ TRErvIIE TYPE TO USED: )AUGERS [I HOSE <br />GROUT SEAL PUMPE): XYes 'No (NOTE: MAXIII4UN FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: 96(±1eLAci_c_ex&al- _Yx„,;tioyl - APPROX. BORING DEPTH 35 r TRA;:FIC EIO.K or Q STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (If YES Rs' spec lfications here):__ - <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOUR:3 IN ADVANCE FOR ALL RE:ouiti-ra) I'MSPECTIONS. -- <br />hereby certify that I have prepared this application and thal the work will be done in .ac con lance with San Joaquin <br />;ounty Ordinances, Rules and Regulations, and all applicable California State Laws. <br />igned x <br />rint Name_ D.COACR.., 3--03 DEPARTMEN7 USE ONLY <br />ITE MAP IN UNIT IV FILE, ADDRESS: <br />fORK PLAN DATED: <br />T INVOICE <br />• / <br />ate Issued <br />InspectIon By °AMMAN dr Date /Alb <br />FA <br />Date <br />Date <br />.11.011m <br />AID* <br />E CODES FEE INFO CHECK if AMOUNT REMITTED C'I) <br />cD3 gr- lt, <br />57 WC -WAIVER C-57 Letter of Autho, -hrtunt do <br />DA <br />AllEap ir <br />lon ,o <br />/0 " <br />it <br />L <br />'Ogaden Accepted By <br />out Inspection By <br />:structIon Inspection 14y <br />MAMENTS / CONDMONS <br />1CCOUNTING ONLY: <br />THIn/Company <br />SITE <br />MITIGATION <br />UNIT IV