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HECOWED WELL PERMIT APPLICATION FORM <br /> SAN JOAQUIN COUNTY " SITE <br /> AUG 2 9 2003 MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> EWIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 =UNIT IV <br /> PERMITISERIAGES (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 Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department_ <br /> �n $1 efv,+ Assessors y� <br /> WELL Location E. Cµ4�i .crass street Cr/�b+! City STa c(KKTON Zip�,7 Parcel# ~1-I- <br /> PROPE S T- a j= J ,0-Y GAADELLA <br /> Owns o (Ad pp—C-0 -x/}NDZAddressrc -S "N.b ST• C NY RuZ Zij�PC.d Phone# <br /> C-V ContractorGmc-4 f u~ Adams 9S"0 HoLae City Irv4R'siu�+ ; 4533 ak.%401 Phor,e#qXS-313-S ao <br /> 5 E !�-ES <br /> Consultant 1 Sub CntrV+ z[C4fT tovi .fXG-17�kddress �e� j N* .57, City:EFC/ Lic# S15o 1 Phone# � 33-0-7 SS <br /> GIS Coordinates:X Y Township ' Range Section <br /> WORK TO BE PERFORMED: <br /> "EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) „ p DESTRUCTION (choose type below) <br /> SOIL BORING# — a OVER-BORE. DIAMETER <br /> WELL# a PRESSURE GROUT <br /> n*Other GROUT SPECIFICATIONS <br /> COMMENTS: ; <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING p HOLLOW STEM DIA.OF BOREHOLE p MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> (I EXTRACTION II AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:, U STEEL 1)PVC p OTHER: <br /> a VAPOR D MUD ROTARY DEPTH OF GROUT SEAL {l 9 / �:TREMIE TYPE TO BE USED: p AUGERS Q HOSE <br /> Q AIR SPARGE!OZONE,,'PUSH POINT(GP or CPT)GROUT SEAL PUMPED:>ZYes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING tJ a HAND AUGER GROUT SPECIFICATIONS / <br /> a OTHER:_ fl OTHER APPROX.BORING DEPTH [ L 9 r I]BOLTED TRAFFIC BOX or a STOVE PIPE rr ' <br /> CONDUCTOR CASING PROPOSED /kr 0 (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. ?a <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinjpness, Rules and Regulations,and all applicable California State Lawt.,s- <br /> Signed x Title/Company Fp- �/ wxiG HTJJvI <br /> Print Name f` s ' Date 3 <br /> DEPARTMENT USE ONLY dT>< ; ST P-t rear Fl 5;— <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: X" ^JF- 24AC0 c GAp --I) 1-11C HN2)17-/a.-1S 3Lz �- 1 20-0-3 <br /> Application Accepted By ✓"v Date Issued 3 `U"`� Area <br /> Grout Inspection By Date Finallnspection By Date <br /> Destruction Inspection Dat <br /> COMMENTS 1 CONDITIONS: 014 b 30 ZOO <br /> e <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# AECID BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3501 84.00 280 - It, Sc jam SR# 3,1 `t <br /> C-57 WCC WAIVER C-57 Letter of Autho zati n t sign permit EncroaChment dot_ 9/30/02 <br /> } <br /> i� <br />