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WELLPERMIT APPLICATION ARM SITE <br /> Q <br /> � SAN JOAQUIN COUNTY <br /> OQ ENVIRONMENTAL HEALTH DEPARTMENT (EHD) 51 <br /> O <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 N 13 2003 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIR N1,'1'- <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is rr�Sie iI�omphance sarith��n <br /> Joaquin County Development Title,Chapter -1115.3 d the Standards of San Joaquin County Environmental Health De artme Assessors E R VICES <br /> 3C 3 '(H.) 1"9" Cross Street City J�e-��ip $C w� Parcel# <br /> WELL Location E 26,E <br /> TlM (7,t!!?S Address �6f` 8830 3 City 5I�I-� Zip k)ke Phone#�/✓ <br /> PROPERTY Owner 1 <br /> C-57 Contractor / <br /> I'Z GII L <br /> 2 <br /> of rtl� Address J � H 1l City lS feu Zip iSGti l Lic#�L` �7 PhoneiEJlE-77��`�/Ez <br /> Consultant/Sub Cntr <br /> ,t Address V y�L�Z City ' �L�U1# 34 75 Phone# 772--36 2C: <br /> Township Range Section <br /> GIS Coordinates:X Y <br /> WORK TO BE PERFORMED: <br /> E$TRUCTION (choose type below) <br /> p NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') VER-BORE. DIAMETER el <br /> Q SOIL BORING# 0 PRESSURE GROUT / <br /> DWELL# GROUT SPECIFICATIONS k, <br /> 'Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Z'` <br /> �NIONITORING D HOLLOW STEM DIA.OF BOREHOLE D <br /> MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> rg EXTRACTION 0 AIR HAMMER/ <br /> CASING THICKNESS 6yl7 TYPE OF CASING: STEEL ^ ',PVC p OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 7�/ TREMIE TYPE TO BE USED: 0 AUGERS OSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes a No (NOTE: MAXIMUM FREE-FALL DEPT IS 30') <br /> p SOIL BORING O HAND AUGER GROUT SPECIFICATIONS BOLTED TRAFFIC BOX or p STOVE PIPE <br /> 0 OTHER:_U OTHER APPROX.BORING DEPTH //6 <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 certi that I have prepared this application and that the work will be done in accordance with San <br /> County Ordin Inc Rules and Regulations, and all applicable California State Laws. / <br /> Title/Company (• <br /> Signed z <br /> ((L-� C I-I-`> 12✓;�^-� Date -� 0 <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, DDfESS: <br /> WORK PLAN DATED: I� IG 03 <br /> ������ Date Issued I _ Jccra✓.%K-i Area <br /> Application Accepted By Final Inspection By <br /> Date <br /> Grout Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> L <br /> ING ONLY: AID# FAC# <br /> FEE INFO AMOUNTREMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 60 Ileo I�t`t I SR# 003245q <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />