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081'14/2003 15: 31 45401 ="' ENVIRONMENTA! HEALTH PAGE 03 <br /> 4640133 <br /> W�ELL PEWANT APPL,v �AT10 FORM SITE <br /> MITIGATION. <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 O�� <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM_DATE ISSUED <br /> described. This application Is made In cornpllance with San <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or Install the work <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> �se55o s <br /> Ae ''`^^� -CQ, ,,� Cross Street `��cT�� city <br /> T� zip 9537(p Parcel# I`�-y90-oy <br /> WELL Location 541 h1 srag} L; p J <br /> PROPERTY Owner <br /> bM kuu, Z Address -10'T V1enr-.f Koa[i _City Trac Zip `IS11S Phone#�ZCA - q� <br /> C-57 Contractor <br /> LV i Co/�Ad ess Jllv/� � Ave- City,ar►�7�P-f =Lia# Phonei,+ID (o�-7b7fP <br /> ��77 l �T eoat 'tib b city Or;r, u�fs Phone>r�`j25�2g3-y98 b <br /> Consultant I Sub Contractor �014 K0 Ip Address) ty <br /> y ,Township Range Section <br /> GIS Coordinates:X <br /> WOR TO BE ERFORMED 11 DESTRUCTION(choose type balow) <br /> NEW WELL/BORING(CPT,�E PROBE HYDROPUNCH HAND-AUT ST�HIs OVER-BORE <br /> MOIL BORING# 'b - 0 PRESSURE GROUT <br /> ELL# <br /> 0-k-) Grout Specifications: <br /> •Other: 1-0 <br /> COMMENTS: <br /> PE OE WELL INSTALLATI N TYPE CONSTRUCTION SPECIFICATIONS <br /> N AMONITORING 0 HOLLOW STEM DIA-OF BOREHOLE MULTIPLE CASINGS?0 YES ,�NO WELL CASING DIA: N <br /> AIR NAMMERIORIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> Q EXTRACTION 0 N TREMIE TYPE TO BE USED: V AUGERS q HOSE <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING HAND AUGER GROUT SPECIFICATIONS_�� q-6- <br /> OTHER APPROX.BORING DEPTH d50 BOLTED TRAFFIC 80X or 0 STOVE PIPE <br /> 0 <br /> OTHER:_U (if YES,lists specifications here): <br /> CONDUCTOR CASING PROPOSED. ( p 5 ,. <br /> it <br /> •COMMENTS: t <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR NCCRROACALL RH QlENT 1 RED PERMITS <br /> ONS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin s, Rules d Regulations, and all applicable California StaSCN-Ote Laws. 5���� <br /> Titie/Company <br /> Signed x �j p <br /> h r�� Date <br /> Print Name tDEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: q <br /> Date Issued Area <br /> Application Accepted By ��•`' L6 Date— <br /> _ ,�,p� Date Final Inspection By <br /> Grout Inspection By Date <br /> Destruction Inspection By <br /> COMMENTS I CONDrrlONS: <br /> ACCOUNTING ONLY: <br /> AID# <br /> EC'D BY DATE PERMIT 1 SERVICE REQUESTS <br /> INVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK 0 R <br /> 7 � � ?�l� 07 S 7 1/25/( <br /> 8� <br /> C-57 WC�WAIVER` C-57 Letter of Authorization to sign permit Encroachment doc <br />