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d•u�N <br /> OUNTY SITE <br /> SAN JOAOUIN <br /> a <br /> IRONMENTAL HEALTH DEPARTMENT MITIGATION <br /> ccWeber Avenue, 3rd Floor, Stockton,CA 95202-2708 UNIT IV <br /> .= (209)468-3449 •Fax:(209)468-3433• Web:www.co.san-joaquin.c. <br /> . a.us/ehd <br /> JUN 17 2004 <br /> WELL PERMIT APPLICATION FORM FILE COPY <br /> ENVIRONMENT HEALTH <br /> p ITJS REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby md _�2h Jaqu n ounty 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 /> WELL Location 1876 Crotxttry Cllab ffiLd. _Cross Street Nl lCn tod�City� zip95223 Parcel# 123--191-01. <br /> PROPERTY Owner �b- MMN SN-V1 _Address 1633 .W. %L-it City 4OC� zip95203_Phone#209 941�-215I <br /> C-57 Contractor WDot4 rd Address P.Q. BOx 6 City L0y]-Sta zip9n1 Lic#_7]gQB Phone# 707 3744300 <br /> Consultant/Sub Cntr dress 3% E.rBa=or.S City d)o l Md Lic#-513857 Phone#9 � <br /> GIS Coordinates:X Y Towriship 1N .'-Range.•/ 6E '' Section z4 <br /> WORK TO BE PERFORMED: <br /> IEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH„HAND-AUGER,OTHER') Q DESTRUCTION <br /> E OVERIBORE D(choosIAMETER below)e type <br /> �SOIL BORING# <br /> YYELL# PRESSURE GROUT <br /> Q'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFI AT S <br /> `MONITORING j{FiOLLOW STEM DIA.OF BOREHOLE 8'yr IOULTIPLE CASINGS?Q YES ;KNO WELL CASING DIA:21' <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL g PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: (]AUGERS VOSE <br /> Q AIR SPARGE Q PUSH POINT - GROUT SEAT.PUMPED: :0 Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: Nft Wltkkl S°°hMtCn4l--2 <br /> Q OTHER: Q OTHER APPROX.BORING DEPTH 'Z7 BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED.n_(if YES,list specifications here): <br /> 1¢ - �.” /8TD t'jGCQa.ti>/37$' 8W 90 r "Pvc Z�7D ?1 Z7 <br /> COMMENTS: r A07— -XO <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACH ENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinan s, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company Prot CleOlcgist, W�stem <br /> Date. <br /> Print Name �Da all <br /> DEPARTMENT OSE ONLY J � <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> DJ <br /> Application Accepted By �✓ "--� ate Issued. 6-Ie-D Area qw G <br /> Grout Inspection By Dale Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE _. .PERMi37.SERVICE REQUEST# ' 'INVOICE`"� <br /> l M SRO`.v. <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc! <br /> r:. WELL PERMIT SITE <br /> EHD 29-02-001. <br /> w.: <br /> 8/17/2003 <br />