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RECENED WELLOERMIT APPLICATION F0% SITE <br /> - NOV 10 2003 1 . SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) _ UNIT IV <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES 11' (209) 468-3449 <br /> lu 3931 ' lky NONON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATEISSUEDGnm <br /> Application is hereby ads to San Joaquin County for a permit to construct and/or install the work described. This applicatiowll YS <br /> Joaquin County Dev#op nt Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> � / Assessors <br /> WELL Location ��/�� �1' r� Cross Street City r4'/� Zip�Parcel# <br /> PROPERTY Owner vle• w Address �1'--K,.•,t-(— _City// Ste— Zip s�'r on e# 91<"f 6z6� <br /> rns,+ /ler- r�r 9V `1,J.S/� 3i -T <br /> C-57 Contractor 1�r lzt C I)Vr(&yr Address 93"' MO Je- City - inel-zip �3 Li one# c/ZS' �' v <br /> Consultant I S4 Cntrb t/ri.Et�+� Address X30;; JtZ2— City �T - Lic# ' 7.5 Phone# 77?,-3CZ1 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: 45 ;i(l)7,P- Pavy tt!'144 <br /> ty/sr/03 <br /> 'PEW WELL I BORING (U,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) D DESTRUCTION (choose type below) <br /> "SOIL BORING# R D OVER-BORE. DIAMETER <br /> D WELL# D PRESSURE GROUT <br /> D*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> Cr"fiCellar 95%eee i 6.. rc..� y:.+:<7✓at <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS fs. h..Fl , �w�e.det�{-arenk i� <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE2'+ D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: "Ce`,V�7��F 7 <br /> D EXTRACTION D AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER: r/lk3 <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS D HOSE <br /> IR SPARGE/OZONE `�pUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes. D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORIN )1 N 111 HAND AUGER GROUT SPECIFICATIONS <br /> D OT ER: D OTHER APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or D STOVE PIPE <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 certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or�ar�ces„Rul se and Regulations, and all applicable California S� Laws. < <br /> Signedx f•✓1(lt'_ -Ld 'w•"''�—� Title/Company alf5�9 ' <br /> Print Named G�1~ h'• ti('�i�':✓lr Date �3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3931 U- <br /> WORK PLAN DATED' //gz- o3 <br /> Application Accepted By +0 fG2/.Son _Date Issued 1112,910-3 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 350( Sg g9'00 X452 c1) ' �` 11 7 03R# 0036125 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />