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I� E\I <br /> FEB 1 9 2003 WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> ENP RMIT/SEF NNIENT c'f %RONMENTAL HEALCOUNTY <br /> TH DIV S ONPUBLIC <br /> SERVICES UNIT IV <br /> (PHS EHD <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> fill-ll' 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 Public Health Services,Environmental Health Division. <br /> Assessors <br /> WELLLocation Linco\n t�,�'E Cross Street O f'rIL E Sir City slot-k;. Zip4S��' Assessor' <br /> 1�7-3b-IQ <br /> PROPERTY Owner Skolkt— 94L-l.P^^1"L-!-IAddress-rCr�1�t'�°t City s4oc M ZipgSZAZ Phone#` <br /> �v.plolai, ^�Cosr-tie•. Address I�5 L44t".t AgtM City Sc' 5\' Zip Q[5112 Lic#�Q�1�41°hone#SOS-Zso- Sa l <br /> C-57 ConUactor (1 �` tll _ <br /> Consultant/Sub ContractorCl'/� (7tle:rp SCev�' Addres!M'to 'AA(k,n1 Pv'L- / Cigjp S�4� Lic# Phone#425 yZb"u'ol <br /> 1 <br /> GIS Coordinates:X �� J u 10'7,1 .Y 1�'l0 11 4-11.3 .Township 11`3 Range fo�- Section 10 <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION O(hoose t pe below) <br /> 0 SOIL BORING# <br /> RE <br /> 0WELL# '( W- 0PRESSURE GROUT <br /> GROUT SPECIFICATION <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> e MONITORING ®HOLLOW STEMDIA.OF BOREHOLE (71• MULTIPLE CASINGS? YES e NO WELL CASING DIA:Zt� <br /> 0 EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESSSc)�LAa 'AD TYPE OF CASING: O STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL V- lot TREMIE TYPE TO BE USED: jtAUGERS OHOSE <br /> O AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: O Yes I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATION ncb ce.%t^b <br /> 0 OTHER:_O OTHER APPROX.BORING DEPTH -Li;, 8 BOLTED TRAFFIC BOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances,State Laws, and Rules and Regulations of the San Joaquin County. <br /> ' CALL THE IT IV ll� ECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed 1W' Title/Company_ < <ny,q,mar(�I Ci�S•vl�t.l,l <br /> Print Name �14•k V'"L��pN^I Date <br /> SITE MAP IN UNIT IV FIAE ADDRESS /WORK PLAN DATED <br /> D AR USE ONLY <br /> Application Accepted By _ Date Issued Area 6 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: A]D# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC' DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2,10( v Zoe B� 1 <br /> C-57 WC/WAIVER- C-57 Letter of AuthoriZ io o sig permi _Encroachment doc_ 7/17/00 <br />