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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> FLU <br /> SAN JOAQUIN COUNTY UNIT IV <br /> A�JG 0 6 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> ENVIRONMENT HEALTH (209) <br /> E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> PERy1131SER\/ICES <br /> NON-REFtfNDABL@ 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�sessor• <br /> �} ��� /AVIQA + Y Ci LSD 1 Zip9S�`+ Parcel#��Y!-z7�1- s{o <br /> WELL Location F� Cross Street ry <br /> Cher vFv—e C, Lob/ Zip S.2#QPhone#7091-333-0 1 S < <br /> PROPERTY Owner -J 'LI A Address IU � ry <br /> fn} 4C9-� Ve-x%>. mac--+ �� ire gs6-r_s ye s i6-7� -S z& <br /> C-57 Contractor C G-fN Address City. GLip Lic# Phone# <br /> �S" WooD3e 1DG-L c# lZZi�hane#'Z�T'��',ci�Z <br /> Consultant/Sub Contractor Sfe U !iE Address PO Ci / <br /> GIS Coordinates X <br /> Y ,Township 3 N Range Section <br /> WORK TO HE PERFORMED DESTRUCTION(choose type below) <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND AUGER OTHER-) Il OVER-BORE <br /> SOIL BO <br /> # - I]PRESSURE GROUT <br /> WELL# <br /> Grout Specifications <br /> 'Other <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS YES NO WELL CASING DIA <br /> EXTRACTION i]AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING []STEEL []PVC ©OTHER <br /> OVAPOR []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED []AUGERS {]HOSE <br /> AIRSPARGE n PUSH POINT GROUT SEAL PUMPED ti Yes Q No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING l]HAND AUGER GPOUT SPECIFICATIONS <br /> OTHER []OTHER APPROX BORING DEPTH [j BOLTED TRAFFIC BOX or j]STOVE PIPE <br /> CONDUCTOR ASING PROPOSED)_(if YES,list specifications here) <br /> Gee N © - -7(4- <br /> 'C MMENTS it 1 t <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCCRROACALL RHMOu RSD INSPECTIONS PERMITN <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi noes, Rules and Regulations, and all applicable California State Laws <br /> Title/Company <br /> Sioned x <br /> Print Name 7 G ' V 1 Date tV <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV PILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Area eP <br /> Application Accepted By Date lssued ,T Date <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS <br /> RE <br /> ID# eerit <br /> MOUNT REMITTED CHECK# REC'D BY DATEPERMTr 15ERVlCE REQUES3# INVOICE <br /> SR# 403 0 �{ <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br />