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RECE ED WELOPERMIT APPLICATION FAM <br /> NOV 10 2003 SAN JOAQUIN COUNTY SITE <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) MITIGATION <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> PERMIT/SERVICES (209 46 <br /> 3931 �x "("1°3 ) $-3449 <br /> Application is hereby ade to San Joaquin CountyforaUperrmiit o construct and/or nstall the work descOribed.ISSUEDATE This application s Jmade in compliance with San <br /> Joaquin County I op nt Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location '%� i,yJ ccr Cross StreetCity ,S' �iy Assessors <br /> Zip Q _� <br /> PROPERTY Owner �11t /w AddressParcel#_ K.L- <br /> Cit � <br /> Zi 5.. <br /> C-67 Contractor V l +�Addres' 1-o 14cae- /cs^ /of p one# <br /> City �'•/feZ.zipfvs53Li `bS�d one# ZS-313SdzrJ <br /> Consultant/S4 Cntr L/' Address_ffiF �ZDZ <br /> GIS Coordinates:Xy City (x - Lis* ., 7j Phone# 7 71� <br /> Township__Range Section <br /> WORK TO BE PERFORMED: <br /> 10EW WELL/BORING (0,GEOPROBE, ) Q DESTRUCTION (choose HYDROPUNCH,HAND-AUGER,OTHER' pe 7owi f(a.y fG (i�k <br /> SOIL BORING#��_ ro(al�O3 <br /> Q WELL# 0 OVER-BORE. DIAMETER pe below) <br /> O'Other Q PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE0'"F G.(Iay 959e'�i ��t <br /> G.��+iW.) Y-':n <br /> Q MONITORING �— CONSTRUCTION SPECIFICATIONS - <br /> QHOLLOW STEM DIA.OF BOREHOLE "' -1i ' ✓r��t`rl`7i f2acr i i,, <br /> 0 EXTRACTION 0 MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: 1rer xl�r7,Allb_ <br /> Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL4546, <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 0 PVC Q OTHER: <br /> IR SPARGE/OZONEAUSH POINT(GP or CPT)GROUT SEAL PUMPED: TREMIE TYPE TO BE USED: Q AUGERS r�ZJ <br /> Q SOIL BORIN �,d HAND AUGER 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTHQIS 30') <br /> GROUT SPECIFICATIONS <br /> UO <br /> ER: Q OTHER APPROX.BORING DEPTH <br /> Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> "o 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 Ord'ha0ces,,Rul and ions, and all applicable California State Laws. <br /> Si ned x_ c✓fL�+�- 7 t./pl/c f <br /> Title/Company it.e2 t GC.yM <br /> Print Name(C'm i�- 0j, C(fi�•fO <br /> DEPARTMENT USE ONLY Date 6 3 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3931 �. l�)er zh �oc��� "'1Toc k4-c,,, <br /> WORK PLAN DATED:/22 I -) <br /> Application Accepted By_ <br /> Date Issued_. 1//2U/UArea_3 rSJ <br /> Grout Inspection By Datet <br /> Destruction Inspection By Final Inspection By Date <br /> Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 350( S,g 89 � 1(5z cN7R It 7 03 SR# by 36125 <br /> C-57 WC--WAIVER— C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> - 9/30/02 <br />