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FDA E C RM <br /> WELL PERMIT APPLICATION FO SITE <br /> is APR 0 8 2003 SAN JOAQUIN COUNTY MITIGATION <br /> > NVIRUNMENT HEALTH ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ' PERMITJSERVICES 304 E Weber, Third Floor, Stockton, CA , 95202 <br /> 0 <br /> (209) 468-3449 (Sp—(�— C bS f r� <br /> tT��' NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED V <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work descrsbed 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 /> ff Assessors <br /> WELL Locatio 'T' 'tom Cross Street t�k dyallhZip Parcel# <br /> PROPERTY ', ��f6� ( �( i <br /> Owner Address C,tys � Zpfk�"� Phanefr f <br /> fo (LS Address 110- e—C 57 Contractor City �t Zip��_ Lic# T Phone# <br /> hn <br /> Consuitant/Sub Cntr Address!p '(t C1 Lic# ��5p1 <br /> - <br /> GIS Coordinates X Y Township Range Section <br /> ' WORK TO BE PERFORMED <br /> p NEW WELL 1 BORING (CP , EOPR E '�H HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER BORE DIAMETER <br /> WELL# 0 PRESSURE GROUT <br /> Q*OtherI `` r GROUT SPE IFICATtONS <br /> COMMENTS 5 tij Ll ei4'-`j N <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING Q HOLLOW STEM DIA OF BOREHOLE 0 MULTIPLE CASINGS 0 MLlLTt-LEVEL WELL OASING DIA <br /> 0 EXTRACTION 0 AIR HAMMER10RIVEN CASING THICKNESS TYPE OF CASING Q STEEL Q PVC Q OTHER <br /> 0 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 0 AUGERS Q HOSE <br /> 0 AIR SPARGE!OZONI POINT ear CPT)GROUT SEAT-PUMPED Yes p No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING HAND AUGER�� GROUT SPECIFICATIONS l\+e –(3310 <br /> ' 0 OTHER jj OTHER APPROX BORING DEPTH r 0 BOLTED TRA FIC BOX or 0 STOVE 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 certify 5IT7 <br /> on and that the work will be done In accordance with San Joaquin <br /> County <br /> Ord all applicable Callforn State Laws <br /> Signed x7 TitlelCompany �x� � (Pnnt Narne Date n <br /> DEPARTMENT USE ONLY nEC�(��`!lr lU <br /> ' SITE MAP IN UNIT IV FILE, ADDRESSt/�•`!��.',4�5 (� <br /> WORK PLAN DATED fly" [� APR 0 003 <br /> Application Accepted lay Date Issued ! LT <br /> ' Grout Inspection By bate Finat Inspection By DatCC7p11iTrCFR1�l <br /> Destruction Inspection By Dale <br /> COMMENTS f CONDITIONS <br /> ACCOUNTING ONLY AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED, CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C)r -f [!S!R# <br /> C-57_ WC�-WAIVE€2T C-57 Letter of Authorization to sign permit Encroachment dacY? 9130/02 <br /> s,JCLu}tc�.1) <br /> COS 40-�- <br />