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D I� ! ' <br /> WELL PERMIT APPLICATION FORM <br /> AUG 2 9 2003SAN JOAQUIN COUNTY SITE <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) MITIGATION <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> 4' PERMIT/SERVICES (209) 468-3449 <br /> 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 This,Chapter 9-1115.3 and the Standards of San Joa uin County Environmentat Health Department. <br /> WELL Location 1333 F. C,9Af 7Ex Ili`/ SSE Assesso f <br /> S'r87 (F411CHCMARa'ER WAY cross street N�✓�4t7.f C;ty 5iocWa.✓ zip 9S?o5 Parcel#! 3" <br /> PROPERTY <br /> Owner PA A IZ Address 1333 F. C&AP7- City$Tour -0A1 Zip_tS_A0S Phone# <br /> C57 ContractorGREGC. ?.ttL� ' r <br /> Address 9j 0 /ti#D tv� /7�, City&+ji!!TrN�ip9�Lic#G 4 'Phone# <br /> _ <br /> Consultant/Sub Cntr1n�R1GNT V(Ro��dress to 7 �• /01* ST C;ty j/�J�GY Lic#�E/ phone# 8 33-07�8 <br /> GIS Coordinates:X Y Township A. <br /> Range Section <br /> WORK TO BE PERFORMED• <br /> ;NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER')' D DESTRUCTION (choose type below) <br /> .SOIL BORING# C — 0 OVER-BORE. DIAMETER <br /> D WELL# <br /> 0*Other 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> E. <br /> D MONITORING D HOLLOW STEM DIA,OF BOREHOLE_L (I MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION 0 AIR HAMMEWDRIVEN CASING THICKNESS N A <br /> - TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: � <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL 7'0 /!f o' TREMIE TYPE TO BE USED: 0 AUGERSk LOSE <br /> D AIR SPARGE/OZONE,PUSH POINT(GP or CPT)GROUT SEAL PUMPED: &Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS :i <br /> D OTHER:_�0 OTHER APPROX.BORING DEPTH_ //9 <br /> 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED ND (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina s Rules and Regulations,and all applicable California State Laws. <br /> Signed x � Title/Company PI�SrT f7i¢NA( R- u/�2t[t¢r'�^�t/VtI�N/��Nle_ <br /> Print Name S Date 7/;Z-3 3 I <br /> DEPARTMENT USE ONLY nJ or€ 5TRs14 r 3 SITE MAP IN UNIT IV FILE,ADDRESS:_._ _5-"5• 14.7—Ihc <br /> WORK PLAN DATED: fvNE 2(p Zoo-3 — 4)IA/¢ v s� w Co-+Z>1T/6AJ.S .iacy 17,2-60S <br /> Application Accepted By Date Issued Area <br /> Grout inspection By Final Inspection By Date <br /> Destruction InspectIo99y__T Dat JI <br /> COMMENTS/CONDITIONS: Zoo 3 1[C <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 35o r SR.( $ ��' 03 sR# 3�I <br /> C-57_ WC--WAIVER— C-57 Letter of Auth zati o SIA permit_Encroachment doc— 9/30/02 <br />