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a <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> 0 6 2003 , ,ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> E1'\1VIR0NMENT HEALTH 304 E Weber, Third Floor, Stockton, CA , 95202 <br /> AUG 2, 0 2003 (209) 4� <br /> PERMfT/SERVICES 8-3449 <br /> +�f„i.NEFUI+IDA LE PERMrr EXPIRES 1 YEAR FROM DATE ISSUED <br /> IS to construct and/or install the work described This application is made in compliance with Sal. <br /> Application is hereby made to San Joaquftl_til Q3UMt}fj +} F} 3 <br /> Joaquin County Development Title,Chapter 9-11 I5 3 and the Standards of San Joaquin County Environmental Health Department Assessor's <br /> R LO'D ! gS�Y oParcel#dyt'`z7t-1-- <br /> �( ,U � (�fl�e,�,(�-E� Cross Street MyR.�Y4y Cary �P <br /> WELL Location 333-4 <br /> PROPERTY Owner _! g <br /> C i !t1 Address /U + C�Pv 'F` City Lo D rp�5^,2�/�hone# <br /> ��13o Vr-iJor! S�rrc� -47 Qpc v illGZi 67 SS �,Ib s1�� <br /> C-57Contractor 5ct rA+e G Z-4 Address City P Ltc# Phone <br /> wooUt-e iDGE jG 12-2> hone 269-3zF- <br /> Consultant/Sub Contractor $f'ea, v oiQ. Address Po O X /57 City t Lic# <br /> GIS Coordinates X <br /> Y Township 3 AJ Range � Section I <br /> WORK TO BE PERFORMED DESTRUCTION{choose type below) <br /> NEW WELL/BORING{CPT GEOPROBE IlYDROPUNCH HAND-AUGER OTHER') i7 17 OVER-BORE <br /> SOIL 130RItirj# 3 0 PRESSURE GROLM <br /> WELL# <br /> Grout Specifications <br /> *Other <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ! <br /> MONITORING HOLLOW STEM DIA,OF BOREHOLE MULTIPLE CASINGS?©YES n NO WELL CASING DIA I <br /> WSPARGE <br /> CTiON AIR HAMMERlDRIVEN CASING THICKNESS TYPE OF CASING OSTEEL 0PVCd OTHER <br /> D MUD ROTARY DEPTH OF GROUT SEALTREMIE TYPE TO BE USED ❑AUGERS Q PUSH POINT GROUT SEAL PUMPED D Yes p No (NOTE- MAXIMUM FREE-FALL DEPTH IS <br /> SOIL BORING n HAND AUGER GROUT ScECIFICATIONS <br /> OTHER APPROX BORING DEPTH _N BOLTED TRAFFIC BOX or {]STOVE PIPE <br /> OTHER (1 <br /> CONDUCTOR ASING PROPOSED” (+f YES,list specifications here} <br /> X16 <br /> 'C 11 <br /> MMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENoR��REQu REo Ns ECT Ns <br /> CALL THE UN17 IV INSPECTOR 48 WORKING HOURS IN ADVANC <br /> I hereby certify that I ha�nces,,Rulersd Red this latlons�landton and that theall applicable Cal forrtlaork tll be done in S ate Laws accordance with San Joagwr� <br /> County Ordg <br /> TitlelCompany V <br /> Signed x <br /> t1 / Date tL' <br /> Pnnt Name_ ��e�l DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> _ _Date Issued 0 .ATea bP <br /> Application Accepted By� Date <br /> Grout Inspection By <br /> Date Final Inspection By <br /> Destruction Inspection By Date <br /> MENTS/CONDITIONS <br /> I <br /> COUNTING ONLY AID# cer +t CODES FEEINFO AMOUNTREMrTTED CHECK# REC'D BY DATE PERMIT l SERVICE REQUEST#SR# 003 br Fnrre¢chment doC JJ <br />