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&- ENVIRONMENTAL <br /> ELL PERMIT APPLICATION FORM SITE <br /> APR 0 8 2003 SAN JOAQUIN COUNTY <br /> W HEALTH DEPARTMENT EHD MITIGATION <br /> AMAMENT HEALTHUNIT IV <br /> ' PERMIT/SERVICES 304 E Weber, Third Floor, Stockton, CA , 95202 <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 /> C L, l Assessors <br /> WELL Locatlo alt k� N"1 f�AhiA_-Ip 6N4rlrross Street SSCity Zip Parcel# <br /> PROPERTY C� fiC -{,.,�l <br /> Owner I '10[Address ,� DCdy-J ILSv Zip?�Z�Phone# <br /> c <br /> C 57 Contractor f IIt f Address City k'C2. ZIP�E3Lic�Phone# <br /> ' Consultant/Sub Cntr kI thS eL C� Address ef�CA `� Lac# �V Phone 97 0rlJI � <br /> GIS Coordinates X Y Township Range Section <br /> ' WORK TO BE PERFORMED <br /> 0 NEW WELL/BORING CP GEOPROBE HYDROPUNCH HAND AUGER OTHER") p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE DIAMETER <br /> 0 WELL# 4ERESSURE GROUT <br /> 0'Other r {{ G UT PEC( (CATIONS <br /> COMMENTS f I� T P J arw <br /> , !J { <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE �n � 0 MULTIPLE CASINGS 0 MULTI-LEVEL ( EL1,,.,CASING DIA <br /> EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS► TYPE OF CASING STEEL a PVC �Q OTHER <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALMIE E TO BE USED 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE!OZON ki POINT(GP orPC&ROUT SEAL PUMPED Q yqs 0 No (N AXI UM FREE FA>_L EPTH IS 30') <br /> 0 SOIL BORING Vv0 HAND AUGER GROUT SPECIFICATIONS (? 1 <br /> 0 OTHER 0 OTHER APPROX BORING DEPTH 2ED 0 OLTED TRAFFIC SOX r STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (it 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 /> ' 1 hereby certI ij at I h e pre red this application and that the work will be done In accordance wit San Joaquin <br /> County Ordi a ces, fes an Regulations, and all applicable Californ tate Laws <br /> Signed x / <br /> Title/Company e f� r <br /> ' <br /> Print Name r Date iv/1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS <br /> WORK PLAN DATED <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS <br /> I, ACCOUNTING ONLY AID# FAC# <br /> i <br /> # PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> S R# <br /> C-57� WC -WAIVER C-57 Letter of Authorization to sign permit,Encroachment doc____ 9/30/02 <br />