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.,.FILE GUFT <br /> G3ECEI MED WELL PERMIT APPLICATION FORM SITE <br /> -SAN JOAQUIN COUNTY . MITIGATION <br /> JAN 0 7 2004 UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) � <br /> ENVIRONMENT HEALTH 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 468-3449 W� <br /> 1 ON-REFUNDABLE PERMIT EXPIRES YEAR FROM DATE ISSUED <br /> AppNcatbn is hereby made to San Joaquin Courtly for a Permd to construct andtor install the work described This application Is made in compliance with San- <br /> Joa' County Deve1oppment Title,Chapyte/r -1115.3 and the Standards of San josquin County Environmental Health Department <br /> s<sogsors 370_0 <br /> WELL Location .S! .J �. /n IJTr Cross Street MkYr�NUP-Cit), %A+Cy ZIP�.�.�i 76 Parcel# 3 <br /> c X <br /> PROPS Go X t 57 F FLIWA Zi S7 <br /> RAY Phone# � <br /> Owner Seo J'A N t CE BftOtaN Address!S 93 ARf�Ot.Jf(�A� Cny v-� <br /> Cfi7 Contractor <br /> V+W �DIZI(—WN&ddress po {�Oy( y 16 City�SLEfaAlTip9S�r Lldf Phone#9 <br /> Consultant/Sub Cntr <br /> NHC*TAfCedress 6-7 9. / —ST• cty RRcy uw�/Sof Phone#�9 -0755 <br /> EPF�(CFS� nuc• 7ownstup Range section <br /> I GIs Coordinates:X <br /> J <br /> WORK TO BE PERFORMED: <br /> U NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ,J �R BORE.CDIAMETER o�type lbw) <br /> U SOIL BORING# (�PRESSURE GROUT <br /> a WELL# tiROUT SPECIFICATIONS <br /> a•Other <br /> COMMENTS: <br /> VF-STP-U(- <br /> TYPEOF WELL INSTALLATION TYPE Nygfl0 SPEc1FICATIONs µA <br /> `KMONITORING a HOLLOW STEM DLA-OF BOREHOLE_ U MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: <br /> U EXTRACTION _ U AIR HAMMER/DRNEN CASING THICKNESS TYPE OF CASING: U STEEL O PVC O OTHER: <br /> U VAPOR U MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS a HOSE <br /> u AIR SPARGE/OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED: U Y� 0 (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> aSOIL BORING aHAND AUGER GROUT SPECIFICATIONS Nor4- HARD Cz $EMToN ITE <br /> ` a OTHER: n OTHER APPROX.BORING DEPTH IS r_19G-S II BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: Wog-Y- Sc�t7vL-ED rOR SANURfL 2004NOTE: OFFSITE BORINGS REQUIRE 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 to done s. accordance with San F Joaquin <br /> j County Ordinances pules and Regulations,and all applicable California State Lapws. <br /> �c�5��nrC . <br /> I SIgnedx G� Title/CompanyfZZEcT MAjul,6EIZ �Vp-IG ENOPrU�E�'�L <br /> i 6F �o cvitJ Date <br /> i Print Name DEPARTMENT USE ONLY <br /> 1{ SITE MAP IN UNIT IV FILE, DRESS: <br /> i1 WORK PLAN DATED: Area �p <br /> L Date Issued / �+ ' O <br /> 111 Application Accepted By to —��' <br /> Grout Inspection By <br /> Da[e Fnal Inspection B <br /> Destruction Inspection By Date <br /> COMMENTS I CONOMONS: <br /> I ACCOUNTING ONLY: AID# FAC# <br /> I PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 350E W (ob ' --3/ ?6 � , , -SR# 4003650-7a <br /> t; C_97_ WC -WAIVED __- C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />