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WELL IERMIT APPLICATION FAM SITE <br /> I�I\ �I � SAN JOAQUIN COUNTY MITIGATION <br /> RE ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> UNIT IV <br /> DEC 1 0 2003304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> [NVIRCNi�tEP,i. nrF;I-:i 11 <br /> PFRPJI'i 1/SEt-i\IICGS 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 /> Assessors / <br /> WELL Location4�ii� �6/t� *i l Cross Slreet�/�06'�/}(r�r.Crtit�y""��, /VAL—ZiP Z� Parcell# 1 —40�'"Z <br /> PROPER , I,�' , 3Sn 1�Ai Le City�NZip jj1f9Phone# <br /> Owner YHC{'�A61nA Address �} `,-']�-• ( �/ p <br /> I Address9J;-01 Ie'L20c7C( City/? Y -/I . ip/.S Lic# Phone ? <br /> C-57 Contractor / //z <br /> Consultant/Sub Cntr VCR E.✓ • Address <br /> GIS Coordinates:X .Y ,Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION (choose type below) <br /> ,dNEW WELL/ BORING CPT, EOPROBE,HYDROPUNCH, HAND-AUGER,OTHER') <br /> SOIL BORING# CD,�T"g <br /> 0 WOVER-BORE. DIAMETER <br /> ELL# 0 PRESSURE GROUT <br /> 0. ELIL / J /GROUT SPECIFICATIONS <br /> COMMENTS: <br /> i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 9 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: /y <br /> 11 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Qe TREMIE TYPE TO BE USED: XAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 AND AUGER GROUT SPECIFICATIONS i n <br /> 0 OTHER: O OTHER APPROX. BORING DEPTH .1 l^112_0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCT R CASING PROPOSED .!/c� (if YES,list specifications in comment section) <br /> COMMENTS: e�f <br /> NOTE: OFFSITE BORINGS RECIUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> CouOrdinances Rules and Regulla�tio�ns, and all applicable California State Laws. <br /> I / )(,/��" Title/Company Y-al <br /> Signed x .y <br /> I _I te <br /> Print Name t/ , Da <br /> DEPARTMENT USE ONLY <br /> 'E MAP IN UNIT IV FILE, ADDRESS: I S l3 S Y �loa� <br /> 1^JORK PLAN DATED: <br /> Date Issued I b j r -(C 2� Area 2✓L <br /> Application Accepted By Date <br /> yip,�� Dale X I (o a Final Inspection By <br /> Grout Inspection By___L � — <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT VOICE <br /> I SERVICE REQUEST# IN <br /> moll`L6 v (.� I <br /> C-57_ WCWAIVER_ C-57 Letter at Authorization to sign permit_Encroachment doc_ 9/30/02 <br /> = <br />