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1i j�� WELL PERMIT APPLICATION FORM SITE <br /> ;i „ MITIGATION <br /> AR 1 0 2003 SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> H�1ViIw.U,IfVILfNT NLALTH 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> PL3n% i T/`sLRVISLS (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES'YEAR FROM DATE ISSUED San in <br /> Application is hereby made to San Joaquin County for a permit tOwn trucand/or is the work described. This application is ma ssessorsl�ance with <br /> Joaquin County DevIe03 en[Title,Chapter 9-1115.3 and the Standards of San Joaquin Country/ Environmental Health Department.arcel# et Ay <br /> i S. Sfi C kl'Jh S}. _Cross Street Kt��(�.•• 1�, Ci 1• /qer L 2ai)36'P-�8P1 <br /> WELL Location 1313 S st kf -2t City /�°4+ Zip LS Phone# <br /> VAIIt � T e{�SLrizs Address (�25�313–Sd00 <br /> PROPERTYOwner 9 'I N1g.}-rtz Zip9`551 Lic# S P Phone# <br /> G t py' (� A Address IJrO /T°M e0( Cry <br /> C-57 Contractor r phona# C9z5)6�r�-1400 <br /> Address .�G5n t°* e.t�e1 tixtkCity °�t°+°3- Lic# <br /> Consultant/Sub Contractor Range_---Section <br /> Township�— <br /> GIS Coordinates:X__— Y — <br /> WORK TO BE PERFORMED: 0 DESTRUCTION(choose type 1]OVER-BORE <br /> JS NEW WELL/BORING(CPT, SOIL BORING <br /> HYDROPUNCH,HAND-AUGER,OTHER') 0 PRESSURE GROUT <br /> Q SOIL BORING# y Nei tt Z�.-f" <br /> rPl – <br /> �>NVELL# Grout Specifications: <br /> *Other: t P t_1 -7I c l <br /> COMMENTS: <br /> INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ' 11 NO WELL CASING DIA:N/A <br /> TYPE_ O_FELL DIA.OF BOREHOLE R +^. MULTIPLE CASINGS. YES <br /> p MONITORING p HOLLOW STEM <br /> 0 EXTRACTION fJ AIR HAMMER/DRIVEN CASING THICKNESS N y� G PE OREM EI TYP OTO 3E USED: 9 AUGERS N HOSE <br /> MUD ROTARY DEPTH OF GROUT SEAL d-1 - <br /> pVAPOR GROUT SEAL PUMPED: Byes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30' <br /> Q AIR SPARGE 0 PUSH POINT t <br /> t� <br /> HAND AUGER GROUT SPECIFICATIONS: )GO �� N��� BOLTED TRAFFIC BOX or [1 STOVE PIPE <br /> 0 SOIL BORING <br /> �-� APPROX.BORING DEPTH .7�- <br /> 9 OTHER:.—H OTHER�� if YES,list specifications here): <br /> CONDUCTOR CASING PROPOSED.�,Q_ <br /> *COMMENTS, <br /> ESS <br /> NOTED OFF SN P BOTOR 48 WORKQINGI HOURSRE CIN DOANCEIFOR ALL KrWOU RED INHMENT SPECTSIONS- <br /> CALL THE <br /> I hereby certify that I have prepared this application and <br /> l ca that <br /> the <br /> Work fill be done Laws,in accordance with San Joaquin <br /> le�ay <br /> County Ordinances, Rud Regulations, and all app�fnRodE�TitlelCompany f <br /> Signed x Data <br /> Print Name "f DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 7/1 D/03 Area <br /> Date Issued Date <br /> Application Accepted By Date b Final Inspection By <br /> Grout Inspection By Date <br /> Destruction Inspection By <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: <br /> AID# care <br /> RECD BY DATE .- PER <br /> /SERVICE REQUEST# INVOICE <br /> PE CODES FEE INFO AMOUNTREMITTED CHECK# <br /> 9 7/10L <br /> 7 rO �? SR# <br /> DIll 8�' t/2 <br /> __ .,� _U/ATVFR _ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br />