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WELL L RMIT APPLICATION FORS, SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> MAR 1 0 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENT HEALTH (209) 468-3449 <br /> PERMIT/SERVICES <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 /> �j�D F. !�f��� � Assessors <br /> WELL Location ' / Cross Street 6;r� City 5�l��I"' Zip�l 5'?D t Parcel# <br /> PROPERTY Owner (, t 7�V 0� S�CC�{tom Address /City Zip Phone# <br /> C-57 Contractor �v� 111 Address 13 q 1/o Cityl/{hq', Zi,0*50 t Lic#7207 Phone# q f&-777—q1,Z <br /> Consultant/S4 Cntrr/C c v Address 60c �?-M Z Citysl2+Ggl6�J Lic# 3`f 75 Phone# 26.T-772- 3(;-2c <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCT!ON (choose type below) <br /> tt a SOIL BORING# a OVER-BORE. DIAMETER <br /> WELL# 0 —L }7) R' 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS / <br /> ,&ONITORING IOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Z ` <br /> r0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS DrfO TYPE OF CASING: 0 STEEL ?TPVC OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 2S' TREMIE TYPE TO BE USED: -PAUGERS OSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes *o (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_a OTHER APPROX.BORING DEPTH `�O r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if 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 /> I hereby certi� that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi an es, Rules and Regulations,and all applicable California State Laws. / <br /> (y <br /> Signed x Title/Company <br /> Print Name V i �'� I�� Date 2wo <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: S 20 - /t <br /> Application Accepted By 5zDate Issued 0 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: #0OL' Z l(J <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3�b 3-1 C) SR# C90 3/63 <br /> C-57 t,/ WC=WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/30/02 <br />