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Fr FILE COPY <br /> nD <br /> ECEWO/Er-WELL PERMIT APPLICATION FORM SITE <br /> SEP 2 6 2003 SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENVIRONMENT NEALTH1304 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 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 /> / , / Assessors <br /> WELL Location 1/00 <br /> J Z 0 D &Alva'yy) �4Doss Street�4� City -M-4tZip �3 7f� Parcell# <br /> PROPERTY U 1 4r-1,1'x 'f"c g5314 �� �` <br /> Owner �D/L.) / Address Lj Vy //N� I City Z / Phone# <br /> C-57 Contractor (,yeCb I P44 Lt i/`j"Address �� /7?W 1 A'7 City M a t��'E ip�—Lic# S/Phone# y Z T <br /> Z <br /> Consultant/Sub Cntr iZ$ AddressZ-2/ AA. City, Lic# Phone#yl s Z 1 3 J J <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> _"Other S'o t- 6.43 GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2 " 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> XTRACT N 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> VAPOR 0 UD ROTARY EPTH OF GROUT SEALC- -7z' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP CPT) ROUT SEAL PUMPED: ees 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> PrOTHER:SP OTHER C P APPROX.BORING DEPTH -7 0 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> (Sirs jJAZ�6& 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 Ordin/-/Z- ces, Rule and Regulations, and all applicable California State Laws. <br /> Title/Company y� <br /> Signed.. p <br /> Print Name " I S r 1-41- LL / /l -J Date <br /> DEPARTMENT USE ONLY �1 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 0 3 <br /> tO� Area <br /> Application Accepted By Date Issued <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By <br /> Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# 7710E <br /> �L <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to Si9fi permit_Encroachment doc_ 9/30/02 <br />