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p-MOMMIEF-5) <br /> WELL PERMIT APPLICATION FORM SITE <br /> APR 0 8 2003 SAN JOAQUIN COUNTY MITIGATION <br /> Ile ENV4RU WENT HEALTH ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ' VIRUIIT/SERVICES 304 E Weber, Third Floor, Stockton, CA , 95202 <br /> PERM (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 descnbed This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-111 3 and the Standards of San Joaquin County Environmental Health Department <br /> 1 Assessors <br /> WELL Locatio T rlhCross Street Ty + dy 7-ip Parcel# <br /> PROPERTY �( tyS�Ck VU I �-3 r 0 �t�� C t 1 <br /> Owner Address II Ci l 2+p Phone# 7 y <br /> t I! e Ci A LI Zi 7 Ltc# &hone# Jb, <br /> C 57 Contractor O l �S Address �Y� tY P <br /> ' Consultant!Sub Cntr , Address CTS City�Llc# YV hZo <br /> one ! p <br /> GIS Coordinates X Y Township Range Section <br /> ' WORK TO BE PERFORMED <br /> p NEW WELL! BORING (CP , EOPR E 'Q@Q!? H,HAND-AUGER OTHER-) p DESTRUCTION (choose type below) <br /> p SOIL BORING# p OVER BORE DIAMETER <br /> [(WELL# a PRESSURE GROUT <br /> a'Other I 1J GROUT SPE IFICATIONS <br /> COMMENTS 5 LI ►t{cT, 20 d A N <br /> ' TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING p HOLLOW STEM DIA OF BOREHOLE 0 MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA <br /> IwEXTRACTION AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING p STEEL p PVC p OTHER <br /> o VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED a AUGERS Q HOSE <br /> p AIR SPARGE!OZON�POINT+ 'ar CPT)GROUT SEAL PUMPED Yes p No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING HAND AUGER GROUT SPEGIFICATIONS� h s�ll b 70��o lJ�l� ,b+.irfc sp <br /> p OTHER p OTHER APPROX BORING DEPTH p BOLTED TRA FIC SOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES last 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 at I hav prep ed this application and that the work will be done in accordance with San Joaquin <br /> County Qrdl ces, s an egulations, and all applicable Californ State taws <br /> Signed x /L Title/Company IX i frJC f <br /> JCS <br /> ' Pnnt Name Z/!! Data <br /> DEPARTMENT USE ONLY <br /> to <br /> ��C�,�'�� DI <br /> ' SITE MAP IN UNIT IV FILE, ADDRESS { Ct 4zrjo <br /> WORK PLAN DATED � ' 003 <br /> Application Accepted By Date Issued !d`d3 i Y TH 1 <br /> ' Grout Inspection By Date Final inspection By OatQERn1ITIFgVIHS <br /> Destruction Inspection By Date <br /> ' COMMENTS i CONDITIONS <br /> ACCOUNTING ONLY AID# FAC# <br /> ' PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST## INVOICE <br /> S R# 00 Z•J <br /> WCC WAIVER.. C-57 Letter of Authorization to sign permit Encroachment doc 7 9/30/02 <br /> Cos.1lo& <br />