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I r 4, <br /> � r <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> [RIECENEDD ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> JUN 19 2003 (209) 468-3449 <br /> Appli <br /> dNiVI wN 1EPl f HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ban Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin C5 v H( i Ie,Chapter 9-1115.3 and the Standards of San Joe uin C unty Environmental Health Department. <br /> Cover GV(j Co�n+r <br /> y /V c Assessor's <br /> WELL Location Cross Street Fr 62 �,y City UTDGK T9/lrip 95v?4 Parcel# <br /> PROPERTY Owner JONrJ AR K£r Address eZlS)��a vaa pj a City 5Tx KTa../ rip9sanH Phonel(2o9)46b�a 715 <br /> C-57 Contractor CASCgADF QTi�IrnA Address3G42.. Omm �I�'e Cit frA r" 9579 L1 r" tb 6 Ibq <br /> Consultant/Sub Cntr &G.F . Address &S 7 509A vV RD atySfocKTM Lic# o2Z Phone#: 46 7/o o 6 <br /> GIS Coordinates:X ,Y ,Township - Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> ;P�VELL# Q 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I ONITORING IOLLOW STEM DIA.OF BOREHOLE I' MULTIPLE CASINGS?MULTI-LEVEL?a WELL CASING DIA_ <br /> 0 RACTION 0`AIR HAMMER/DRIVEN CASING THICKNESS Sc �1c TYPE OF CASING: p STEEL XPVC p OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL / TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br /> p AIR SPARGE/Ozone p PUSH POINT GROUT SEAL PUMPED: $YeOs 'N <br /> o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING n HAND AUGER GROUT SPECIFICATIONS: 0.TIRN D T <br /> 0 OTHER: fl OTHER APPROX.BORING DEPTH J 2 S rOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> �\+C <br /> CONDUCTOR CAST PROPOS5Q? (if YES,listspecifications here): <br /> 'COMMENTS: JG'E A0 A oveD kkjo � / hT£ O I /`I I A A <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT 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 Ordinances, Rules and Re uI tions, and all applicable Californ�ia�/7�State Laws. C <br /> Signedx pp Title/Canpany / ISd\FLT V-E9 <br /> Print Name V . C FIS Date Ob- 4-s3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,AD RESS: <br /> WORK PLAN DATED: -O z, <br /> Application Accepted By. Date Issued u Area <br /> Grout Inspection By Date Final Inspection Byr *^^v + ..Date <br /> -_Li A,u I gyp, 7 <br /> Destruction Inspection By Date _- <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS RECT BY DATE - PERMIT/SERVICE REQUEST# INVOICE <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ �--`13/29/02 <br />