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WELL PERMIT APPLICATION 09RM SITE <br /> RECM v E[4, MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> JUL 102003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENT HEALTh (209) 468-3449 <br /> -PERMIT/SERVICES <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 9-11 5.3 and the Standards of San Joaquin County Environmental Health Department. [r �f <br /> ,n Assessor's,6 <br /> WELL Location v V - edCross Street City hd'� Zip Q///r���M�"�Parcel# !✓r r� D�' �j&4 <br /> �p 9-K n-1 IXC <br /> PROPERTY Owne^r.'lJn�/��/` �S��pE Addresset d � City �/ � Zi Phone# �39� IL9 <br /> C-57 Contractor lJ�`1'1 ICS �r�cLAddress ZO L54`.0,111 City u ,l�Zlp Lic44/ Phone#4 -' _ <br /> Consultant/Sub Contractor Address City. Lic# Phone# <br /> GIS Coordinates:X 'y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> *Other: <br /> 0 WELL# Grout Specifications: (_t ^(1_gel fT, XRESSURE GROUT <br /> COMMENTS: bbTG&'^J s 5`6(A_ S-bit30 �61y LaTT/9 K -rV —777 I@ . <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS (�_ <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:_ W` n <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: `CJI <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> p AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> C NDUCTOR CASING P OP (if YES,list specifications here): <br /> *COMMENTS: I <br /> C <br /> NOTE: O FSITE BORT GS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. I <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O i ance , R +tat' /ns, and all applicable California Sta Laws. , <br /> Signed x J Title/Company 0 <br /> Print Name V, 4 _t • CL a r« Date4k/o R <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATELD:: p p <br /> Application Accepted By /-'�/��^8-��(c Date Issued 7/11/V; Area 997 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By ` Date I 6; <br /> COMMENTS!CONDITIONS: 3xt Js 2L64 eSrtp SFIA#QPE a-- S 5;4 RcL, <br /> ACCOUNTING ONLY: AID# rerx <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> nU 60- (oo 9D-A(0 ' 14le-- 7 !/ A3 SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 1/25/02 <br />