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} <br /> jVVEDD <br /> WELL PERMITAPPLICATION'_" FORM SITE:`: <br /> SAN JOAQUIN COUNTY .. <br /> MITIGATION <br /> AUG 2 9 2003` ENVIRONMENTAL-HEALTH DEPARTMENT'(EHD) „y. - <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV � <br /> ENVIRONMENT IiEAI_TK (209)468,3449 <br /> PERMIT/SERVICES NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM(DATE ISSUED <br /> Application is hereby made to San Joaquin County for a pe dlor install the work described. This application Is made in compliance with San <br /> Joaquin County Develo ment Title,Chapter 9- 15 f S8 Standards of SomanJc_0q County Envirtinmental Health Department I <br /> WELL Location SEreet . 1 -1t Cky SToc. n�✓ Zlp g��oS P'a�rGeae I O'Q57 <br /> PROPERTYVo HR. FDAEST W14ITF <br /> Owner SAIV SO4 Qul AJ 0&0f" Address/16sL3 S.AIRPdQ%„wY City Sia CK rV 4 Apype�_PhonelF <br /> S7jN IA-IC. <br /> C-57Contractor45"6G ZX(L..1NGyAddress 9SG HeryE AI). <br /> /�r cnyHAr2Zip44SS3tic#jK(-4O'Phane# 91S-3r3-.SBaA <br /> 56 ( 4 <br /> Consultant/Sub CntrWRIGFIr5NtA"4o 9/fi�ddrless G7 4 /4m 57 : City 2±C Uc#6S/sa/ Phone#Zo9- 833-07.s$ <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED; <br /> XNEW WELL 1 BORING CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL BORING# pT 3 11D OVER-BORE. DIAMETER <br /> n WELL# a PRESSURE GROUT <br /> 0'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS +i- <br /> a MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE a" ©MULTIPLE CASINGS 0 MULTI-LEVEL WELL.CASiNG DIA: r <br /> a EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESS ~ TYPE OF CASING: D STEEL a PVC q OTHER: �1 <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL !li�� TREMIE TYPE TO BE USED: 0 AUGERS HOSE ' <br /> U AIR SPARGE!OZONE %PUSH POINT(GP or CPT}GROUT SFAs.PUMPED: ,g Yes: 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING. 0 HAND AUGER GROUT SPECIFICATIONS t <br /> OTHER: R OTHER APPROX.BORING DEPTH IIl BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED No. (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENTOR 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, Rales and Regulations,and all applicable California State Laws. <br /> it !AZ <br /> Signed x_ TtlelCompany ECT f�ANi4Gt� ' WR�f�,—�ivVllEoNl ! <br /> Print Name Date 7 /.2-3 3 <br /> DEPARTMENT USE ONLY Tr- ! S7F-I K-€ s 3 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: SICE F/G agger A I <br /> WORK PLAN DATED: cTv�F Rro X003 — �ICcE?i�r7. w Co�D.Tia.vs ,Tucy' f 7 ?-oe3 <br /> 1 <br /> Application Accepted By Date Issued " L Q ?W Area <br /> Grout Inspection By Datefinal Inspection By'1 .Date <br /> Destruction Inspection By Date i! <br /> COMMENTS 1 CONDITIONS: C e,5S <br /> ACCOUNTING ONLY: AIC# r=AC# <br /> ! ff I I <br /> ^GOES -F=- INFO .��tCUNT RE',11TTED CHECK BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> , I <br /> CK) Zg �; j s>an 33 <br /> C-57_ WC -WAIVER C-57 Letter of Au#ho za#' i9d permit_Encroachment.doc_ 9/30/02 # <br />