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FILE - CUT <br /> ���Ea�EDWELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> MAR 3 1 04 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENT HEAI-TH (209) 468-3449 !/ u <br /> ENVIR�I`�SERVICES dl� COS DS-t <br /> PERM NON-REFUNDABLE PERMIT EXPIRES 1 YEAR fITOM DATE ISSUED 1 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install Me work described. This applicaticrl"is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health DepaMNnt. <br /> Assessors <br /> WELL Location 140 CaR ILL 1?%I-& 4 Max&:Cross Street City $T LA.-tur l Zip gggTParcel# <br /> PROPERTYOwner CLT`( OF STDcXTUA Address3 S_b EL DeriADocr. CityS7Dc 2k1 , Ztp.-L ZPhone# 2D9-l{3'a-rAL3] <br /> G67Contractor Wj'_A?"r>!=w Address 2wCy7o�LfSl " Phone# 2nh-46S -C}r2 <br /> Consultant/Sub CntrKLGrr.tF£tAF.g.,i#.V-. Address UZCf,. M'IP-TLT-- Uo# Phone# 2C9.-44'6-124s <br /> GIS Coordinates:X ,Y .Township___i Pi Range____6F_—F. Section <br /> WORK TO BE PERFORMED: <br /> gNEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> g SOIL BORING# a OVER-BORE. DIAMETER <br /> I*Other <br /> WELL#QS-►-3dPot-1-60tOi-1-901t 7oM..ih- ] wEwi� [I PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: ONLt. o�n.tte SPA¢G.r+JG. w�.t.t-$ �' AD��+ui+f� 't 0t cI!Pe sc.E- I6..Lr� <br /> 1µs?re....fz0 N+ P �'Tt•1 <br /> Of 30' L8' Ar+.+r�`9J' ar%62.o G QO ...ID kg T* F. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS tl <br /> a MONITORING POLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:1^ <br /> g EXTRACTION L AIR HAMMER/DRIVEN CASING THICKNESS $c P- 40 TYPE OF CASING: g STEEL BIPVC g OTHER: <br /> O VAPOR MUD ROTARY DEPTH OF GROUT SEAL4U&W L.W TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> )QuR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: JEYes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> B SOIL BORING p HAND AUGER GROUT SPECIFICATIONS NEhT C&1-%b .Lr <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH'lt`tsbr o na G.d $BOLTED TRAFFIC BOX or p 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 /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinance r Ruiss and Regula ns,and all applicable California State Laws. <br /> Signed x Titie/Comparry Sihff bell trJ 5.6.k.. {LL.frt,.l f-6 Lll. <br /> Date 3� 03 <br /> Print Name DEPAR MENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: IID N• <br /> WORK PLAN DATED: ��15- 3 <br /> Application Accepted By, `T�/(�.� 2� Date Issued 7-/O.3 Area Ob9' <br /> Grout Inspection Ih Date___ _ Final Inspection By Date <br /> Destruction Inspection By Date _ <br /> COMMENTS/CONDn10NS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED I CHECKS RECD BY DATE PERMIT(SERVICE REQUEBT# INVOKE <br /> 3�1 &9 ' P3 six# O3 <br /> C-57 WC-!C--WAIVER--- C-57 Letter of Authorization to sign permit_Encroachment doc g 9/30/02/ <br /> ,C'w"�o3-aSu1 <br /> coce,+w 6.775(0 <br />