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fI <br /> i <br /> ° FE�i V rt-�-,[n) <br /> ELL PERMIT APPLICATION FORM SITE <br /> LAPR 0 8 2003 SAN JOAQUIN COUNTY <br /> IRONMENT HEALTH ENVIRONMENTAL HEALTH DEPARTMENT (EHD) MITIGATION <br /> ' PERMIT/SERVICES 304 E Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (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 /> LL,, j Assessors <br /> WELL Locatl4IV 1�Au� 'tQ 61� ass Street L55 City S Zip Parcel# <br /> PROPERTY G� G r, 7 <br /> Owner I J 10c Address ') Cily� 11 Zip��Phone# 237 -3�'T (4/r <br /> C 5T Contractor f ( Address City <br /> LL krl ZipM�3Lic0 Phone# 26-31 J?(�f yW <br /> Consultant/Sub Cntrl L el Address esTCil � Lic# �4` 4 L�J 1 Phone Dy / <br /> GIS Coordinates X Y Township Range Section <br /> ' WORK TO BE PERFORMED <br /> p NEW WELL/BORING 0 GEOPROBE HYDROPUNCH HAND-AUGER OTHER-) 0 DESTRUCTION (choose type below) <br /> a SOIL BORING# Q OVER-BORE DIAMETER <br /> a WELL# .).PRESSURE GROUT <br /> a-other r GRPUTISPECIFICATIONS <br /> COMMENTS r <br /> t <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA OF BOREHOLE f� , a MULTIPLE CASINGS a MULTI-LEVEL AELI„CASING DIA <br /> W <br /> RACTION a AIR HAMMER/DRIVEN CASING THICKNESS y " � TYPE OF CASING STEEL 0 P+�VC�0 OTHER <br /> OR [I MUD ROTARY DEPTH OF GROUT SEAL MIE E TO BE USED a AUGERS a HOSE <br /> p AIR SPARGE!OZON SEi POINT(GP or q&ROUT SEAL PUMPED p s No (N AXI UM FREE FALL EPTH IS 30') <br /> p SOIL BORING �VTD HAND AUGER GROUT SPECIFICATIONS '� S� 1 <br /> a OTHER a OTHER APPROX BORING DEPTH p OLTED TRAFFIC BOX grASTOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 cera at 1 h e pre red this application and that the work will be done In accordance wit San Joaquin <br /> County Ord a ces, les an Regulations, and all applicable Californr tate Laws <br /> &2�- <br /> Signed x / Tslle/Company "'4 fj �r5 r Ar <br /> ' Print Name ! ' VaL� Date 7 <br /> DEPARTMENT USE ONLY <br /> ' SITE MAP IN UNIT IV FILE, ADDRESS <br /> WORK PLAN DATED <br /> Appiicalion Accepted By Date Issued Area <br /> Grout Inspection By Date Final inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS f CONDITIONS <br /> ACCOUNTING ONLY AID# FACu <br /> CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# <br /> C--57� WC -WAIVER C-57 Letter of Authorization to sign permit—Encroachment doc— 9/30/02 <br />