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• • FILE COPY <br /> WELL PERMIT APPLICATION FORM SITE <br /> RECOVED SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> MAR 1 3 2003 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> 468-3449 <br /> 209) i <br /> ENVIRONMENT HEALTH ( <br /> ERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED e <br /> \pplication ereby 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 /> n 1 Assessors <br /> YELL Location I�lti1' seI -r\ f g Cross Street e f �J� ity ^r f Zip Parcel# <br /> 'ROPERTY Owner ('>,> 5- rk 4..Dtyllo Address 43cx�,:1 C4 S�" 1Cityweln C� Zilf74pt59 Phone#1TZO?? IfZf <br /> -57 contractor P,-,11 I Address �O t lOtr�4 .4 City c },W Zips+�Lic#9p5 Phone# ?7-� 3 3 S8w <br /> U6 C ddress 61�IE1(L.nlfi 96e Clity�. 1 Lic# Phone# 52 16 � 4L�ZL 90 <br /> :onsultant/Sub Cntr� <br /> 31S Coordinates:X 'Y ,Township Range Section <br /> NORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) p DESTRUCTION (choose type below) <br /> SOILBORING# fFJ J II OVER-BORE. DIAMETER <br /> a WELL# 0j. ()PRESSURE GROUT <br /> O'Other 0 b GROUT SPECIFICATIONS LR2AWo.V A /y <br /> COMMENTS: UU <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING HOLLOW STEM DIA.OF BOREHOLE II o MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: — <br /> EXTRACTION ME DRI N CASING THICKNESS TYPE OF CASING: 0 STEEL ()PVC 0 OTHER: <br /> Q VAPORMUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: l)AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 31 <br /> k SOIL BORING []HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH LO—�b t H BOLTED TRAFFIC BOX or 11 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 certify tat I have pre ared this application and that the work will be done in accordance with San Joaquin <br /> County OrdIna a Rules egulations, and all applicable California State Laws. <br /> 1 r <br /> Ap <br /> Signed x Title/Company c em Zi(,�'rn�e)r Zct& <br /> r7 �7 V <br /> Print Name M e 1,, li Date J =z <br /> DEPARTMENT USE ONLY H o <br /> C' W U <br /> SITE MAP IN UNIT IV FILE,ADDRESS: CD <br /> N (S✓�suOO�„ z <br /> WORK PLAN DATED: ZZ ¢ E <br /> c <br /> Application Accepted By df Date Issued 03 Area <br /> Grout Inspection By Date Final Inspecon Date---1 T <br /> Destruction Inspection By Date t <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �401 a 2 6(o levcQ- I 'J-li-o SR# 00 30-7-3 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc 9/30/02 <br />