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• • <br /> REC ENED WELL PERMIT APPLICATION FORM SITE <br /> SEP 0 8 2003 ENVIRONMENTAL <br /> JOAQUIN COUNTY MITIGATION <br /> ENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a peril 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 /> epartmentAssessors <br /> WELL Location /6 67, 4eghgM EK- LN. cross Street WEST LA'. City ,STOcrCTJN Zip 952/0 Parcel# 09µ280PRO1t <br /> Owner <br /> K/MCO R�fF1-7Y Address 5138 MA-PZ4A/1rh cityCAR/1JCNAE�ip 9S6b6'Phone# yl6 ly -7f`8o <br /> C-57 Contractor Vl/LoNEN Address Z/10•'4C74RJ' Adm. Cily�&kW7JZp9Uc#20 142 Phone#S/a'56 9-176)6 <br /> Consultant/Sub Cntr /t CispF ptp Address 7/33 Kcu cev- r City P A^�0''ue# Phone#9LS489V-1706�-Zz r <br /> GIS Coordinates:X ,Y ,Township Z/1 Range 6 qE Section /T <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTRUCTION (choose type below) <br /> WSOIL BORING# Kb-(::7� Q OVER-BORE. DIAMETER <br /> Q WELL# Q PRESSURE GROUT <br /> Q•Other, GROUT SPECIFICATIONS <br /> COMMENTS:_ Co/ 1302ra/(iS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA OF BOREHOLE_ Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE )IftSH POINT(GP or CPT)GROUT SEAL PUMPED: 4Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> XOIL BORING Q HAND AUGER GROUT SPECIFICATIONS NQt'T ce e4T <br /> Q OTHER: fl OTHER APPROX BORING DEPTH-1-0-3-0 Ir Q BOLTED TRAFFIC BOX or Q 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 that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ori nces, Rules and Regulations,and all applicable California State Laws. <br /> Signed x / Tide/Company <br /> Print Name �) ,Pym' 1✓H. L,//}G/!B'- GES /Z9 rF Date !/s� 3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FI ADDRESS: �/ C - J <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued 63 Area 99 IrF <br /> f l/t� <br /> Grout Inspection By Date t 0 3 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: 5LkY -ZO <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> -4701 $wT - gq' III ",; I g.41— 4 R of SR# 00 L <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9130/02 <br />