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RECENEDD <br /> C- <br /> APR 0 $ 2003 WELL PERMIT APPLICATION FORM SITE <br /> SAN ,lOAQUIN COUNTY MITIGATION <br /> NVIRONMENT HEALTH ENVIRONMENTAL HEALTH DEPARTMENT (EHD) MITI A <br /> PERI��IT/SERVICES 304 E Weber, Third Floor, Stockton, CA , 95202 <br /> 1, �IQ- r (209) 468-3449 <br /> �' 3D <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ' Apptication is hereby made to San Joaquin County for a permit to construct andlor install the work described This application is made in compliance with San <br /> Joaquin County evelopment Title Chapter 9-1115 3 and the Standards of San Joaquin County Environmentat Health Department <br /> �{'f� Assessors <br /> WELL Locatio ��� N 4d�#� ross Street [� c1 City C 1� l Zip Parcef# <br /> ' PROPERTY �o �n ' <br /> Q <br /> Owner C ress �/Q�� Cary ip f� Phone#zQ?L(f ✓�5C� <br /> C 57 Contractor (6 AL' .p�, Addresslr_11l Cit �( le1joZIA Licf �lv?7 Phone#�✓� - E�;�7Yi�P <br /> ' Consultant l Sub Cnlr [ Address City_Sj�,02�Lic#_Phone# <br /> GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/ BORING (CP E P DROPUN ,HAND-AUGER OTHER-) v RUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> ' 0*Other GROUT SPECSFICATIONS <br /> Nl E N S <br /> U� 4� / J M �2 <br /> ' TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE_ i-0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING 0 STEEL 0 PVC 0 OTHER <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL , <br /> TREMIE TYPE TO BE USED D AUGERS D HOSE <br /> 0 AIR SPARGE/OZONE--91PUSH POEN {G PT)GROUT SEAL PUMPED 0 Yes 0 No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS, O t1Q . — / <br /> ' 0 OTHER 0 OTHER APPROX BORING DEPTH 2!5 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (d 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 cent at I lieu pre red this application and that the work will be done In accordance with Sart Joaquin <br /> County Ord a ces s a Regulations, and all applicable Callfor State Laws <br /> Signed x ° Trtte/Company <br /> ' Print Name Date <br /> DEPARTMENT USE ONLY <br /> I I PL <br /> ' SITE MAP IN UNIT IV FILE, ADDRESS r C.Lu(,S [}�S <br /> WORK PLAN DATED APR n o ?11 � <br /> Application Accepted By Date Issued ! 'Z/j F-AWIn5�-� L-1 I 11 1 <br /> nninhlrea <br /> r <br /> Grout Inspection By pate Final Inspection By� n[rd�9ierierr <br /> lull r,�� <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS '�T7 cC <br /> ' ACCOUNTING ONLY AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> �OC '!S'� -- f/ <2 <br /> C-57 IJ WCC WAIVER_ C-57 Letter ofAuthorization to sign permit__-_ Encroachment doc_ 9/30/02 <br />