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WELLVERMIT APPLICATION FO'sM SITE <br /> SAN JOAQUIN COUNTY TION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> JUN 1 $ 2003 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NVIRUNMENI HEALI H NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicatiortlt h0!0*%0kkKU 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 /> If 11 r 1 11 /I __II Assessors <br /> WELL Location �Vr-K E R:oAc-(o4 w o���Cross Street Vre'rer Rol. City /-Got i Zip`7st`fo Parcel# N A <br /> PROPERTY Owns CC/4411nfs- Address p•�. WI 2:CHS Ciao-�_Zip9 2-( Phone# 7 :9;G <br /> C-57 Contractors c o-"1 4Address 95c ftot�b1 zl. /Ciity a chez Zip4y�Lic#4S Phone#[Y7S 313-b8o� <br /> Consultant/Sub Crit Address Address *�O Pt�AS-Y.City Sens One LIc#RG-_GZ�Phone#L�c QSS- S•HS0 <br /> GIs Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: _ <br /> .,ANEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) []DESTRUCTION (choose type below) <br /> a SOIL BORING It []OVER-BORE. DIAMETER <br /> 4WELL# MW-S 4AAL--)-j PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> $MONITORING ,HOLLOW STEM DIA.OF BOREHOLE g MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS Sc(,gO TYPE OF CASING: 0 STEEL UVC 0 OTHER: <br /> 0 VAPOR MUD ROTARY DEPTH OF GROUT SEAL `(O TREMIE TYPE TO BE USED: ,$AUGERS a HOSE <br /> 0 AIR SPARGEt OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: RYes 0 No (NO/TE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS I�.r�(Q.,ol GQ-M Girl zr6z <br /> 0 <br /> OTHER:_0 OTHER APPROX.BORING DEPTH 6 a liCBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> ''// CONDUCTOR CASING PROPOSED?—"' (if YES,list specifications in comment section) <br /> COMMENTS: Se,L 116c co( Jif, a clnrn.•t,f7 r- -Yf <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x _ Title/Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: �// <br /> Application Accepted By 1T'C!�i/� 6.44 �. T. �� Date Issued ✓4t `� �� d2 Area <br /> Grout Inspection B V Date Final Inspection By Date <br /> Destruction Inspection By Data <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# JECTABY DAT PERMIT/SERVICE REQUEST It INVOICE <br /> SR# 3 �l <br /> C-57 WC WAIVER_ C-57 Letter of Author za 'on to ign permit_ Encroachment doc 9/30/02 <br />