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WELL a --RMIT APPLICATION FL- Al SITE <br /> `� (������ SAN JOAQUIN COUNTY MITIGATION <br /> H <br /> NVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT. IV <br /> AUG 2 2 2003 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENT HEALTH (209) 468-3449 i' I L E COPY <br /> PERMIT/SERYICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to an oaquin 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,Cyh�pter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department_ <br /> WELL Location/t/ / d- 1v` We ;Cross Street Ci n �lessors <br /> /G' �r city <br /> ��&`� Zip 7J� � Parcel#/� ,}�� <br /> PROPERTY Owner//--" Address j / Vb -City-/ ,/�—Zp 9��hone jAj/ �l-'�e�p <br /> C-57 Contractors!/, FQ, ��(/��^, 'Address C/L(/ Ci 771C` k4/Zip. Lic#( �� hone#Z 7-/16d(o <br /> Consultant/Sub CntrEAddress92L City< ic# Phone# <br /> GIS Coordinates:X _,Y Township Range Section <br /> WORK TO BE PEB®RING <br /> D: <br /> NEW WELL/ CPT GE PROB ,HYDROPUNCN,HAND-AUGER, OTHER') L'DESTRUCTION(choose type below) <br /> SOIL BORING#_ � p OVER-BORE <br /> WELL#_ __ 0 PRESSURE GROUT <br /> *Other:---- Grout Specifications: <br /> COMMENTS - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I7 MONITORING o HOLLOW STEM DIA.OF BOREHOLE '/ MULTIPLE CASINGS? MULTI-LEVEL? U WELL CASING DIA: <br /> ❑EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS V-A TYPE OF CASING: []STEEL 0 PVC 0 OTHER:---/� - <br /> VAPOR o MUD ROTARY DEPTH OF GROUT SEAL ? ,?/z'- TREMIE TYPE TO BE USED: AUGERS a HOSE <br /> 1]AIR SPARGE/OZone)(PUSH POINT GROUT SEAL PUMPED: a Yes 2-No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING 6 HAND AUGER GROUT SPECIFICATIONS: tZnSd W P Az-W7- # T ((a,¢ <br />(1 OTHER: --17 OTHER APPROX.BORING DEPTH ,g,0 f BOLTED TRAFFIC 80— []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? Alz) (if YES, list specifications here):_ <br />`COMMENTS: /(wcJ ,��'rr�CY dJr i l�AS / �S29t Z Ti � 7'J - <br /> e <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 /> noun Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed xr Title/Company <br />'rint Name i r'Vl )PJ (,SCJ L W� A CIA Date <br /> DEPARTMENT USE ONLY <br /> 31TE MAP IN UNIT IV FILE, ADDRESS: 104 W eved Li Place <br /> NORK PLAN DATED: \ cnLia rU Q 200 D <br /> kpplication Accepted By V je+0,r 1 a IVIG rhe&t Date Issued ,?S �oo 3 Area M55 <br /> grout Inspection Bye %` �� Date 2 b3 Final Inspection By `U ` Date 8 3 <br /> �!� j�i �� <br /> destruction Inspection By / Da e <br />:OMMENTS/CONDITIONS:Z or s 2 S I 11"I4CE <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 501 $y.00 ��9 p� l9i« SR oo34 99 3 <br /> -57 WC WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ 8/29/02 <br /> ,t., <br />