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R WELLVERMIT APPLICATION FSM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> JUN 1 $ 2003 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> jNMENT HEALTH (209) 468-3449 <br /> 1 AIT/SERVICES NON-REFUNDABLE 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. <br /> (- Assessors <br /> WELL Location Zccoo �t-F�+'nnlI Vn,J Cross Street Ur-4-- I/ ek city Lsol' I 1 2ip95ZN0 Parcel# /VA <br /> PROPERTY Ownsrg !T! o o..cft.,.�c Address:?-4 isj �•*�� ry r `�(Citys4cc k.7o-i Zip��Phone# Zt R y�-252- <br /> C-57 Contractor G=?,W DIW(f Addrasa �� sl��/� City�grv4TipR�Lic#`�6Ics Phone 494 'W13-5800 <br /> Consultant/Sub Crillor 7rJriS Address=� -tit ti3 5� CityUo#� - ZI Phone# ?3S'ivSc, <br /> GIS Coordinates:X ,V ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> `jicNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> gWELL# Mw -1 C []PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 11WONITORING IWOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Z <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS w L.-i0 TYPE OF CASING: 0 STEEL gPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL yo/ TREMIE TYPE TO BE USED: XAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes p No t(NOTE' MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING p HAND AUGER GROUT SPECIFICATIONS �C r7�q. 4 GaL'n& 4 — Z-22 <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH 6C / BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOD No (if YES,list specifications in comment section) <br /> COMMENTS: '4'c r9Petv <br /> NOTE: OFFSITE BORINGS REQUIRE ACC SS 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 7V, o�/ Title/Company5¢17.'0r_STO y'"1 GQ,o�O CQ n i <br /> Print Name G2 o:25=) A44 Date S Z. o <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By / Date Issued 0 W <br /> Grout Inspection By ate Final Inspection By <br /> Destruction Inspection By Date r u <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> V . <br /> 0R# <br /> C-57 WC WAIVER_ C-57 Letler of Auth eiz i to sign permit_Encroachment doc_ 9/30/02 <br />