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� i�=;�[ ,;� WELL PERMIT APPLICATION FORM SITE <br /> t �i MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> JUL 10 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> W RuNj%ftEN VIEALTH 304 E. Weber, Third 2 Floor,468 3449 ton, CA., 95202 <br /> PERPJIT/SERZ,FE <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDin <br /> Application is hereby made to San Joaquin County for a Perm' <br /> to col andlor install the work described. This application is made sessorsliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. 0V 0-/0 <br /> tt�� `�5Z,f( Parcel#Gtt7- <br /> _CrossSVeetRt�'�),! c„ 1. City ���� ZAP <br /> LL St `5S YO Phone# �2y9)J'�'7-�-Z0? <br /> WELL Location 9�� S S+ +- [. 71 A1.,,YI L(Lr}S Citychi Zip <br /> ,f(ue1eS Address n (925)313-5800 <br /> PROPERTY Owner P0.t �i TbA'I r '�s0 �} r i2 City� f�sz Zip 9K5 _3 Lic# 50 7 Phone# <br /> Address o d • Ci rr <br /> C•57 Contractor ru r5 Phone#L9Z3)6 <br /> �G .2 s [.ir�I trcleCity CcntO✓°� Lic# <br /> 2� Address S <br /> Consultant I Sub Contractor Ranger—Section <br /> Tovmship�._-- <br /> GIS Coordinates:X_�Y�— <br /> W ORK TO BE PERFORMED: p DESTRUCTION U(choose <br /> OVER-BORE <br /> NEW WELL t BORING(CPT SOIL BORING <br /> HYDROPUNCH,HAND-AUGER,OTHER') �PRESSURE GROUT <br /> G SOIL BORIN b.#^ q <br /> DWELL#_�.�— Obiv /`/.eaf Ce u t <br /> Grout Specifications: / <br /> *Other: L <br /> COMMENTS: <br /> TYPE OF WELL INSTALS CONSTRUCTION SPECIFICATIONS S L C <br /> HOLLOW STEM DIA.OF BOREHOLE 10 i n. MULTIPLE CASINGS?p YES �NO WELL C07Fi RDIA: <br /> SMONITORING D )r, b TYPE OF CASING: 0 STEEL I PVC <br /> a EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESS 5T It <br /> DEPTH OF GROUT SEAL V"- `f 6' �- TREMIE TYPE TO BE USED: _J P.UGERS 0 HOSE <br /> p VAPOR D MUD ROTARY T <br /> PUSH POINT GROUT OF <br /> UED: ®Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30'; <br /> F AIR SPARGE U GROUTS <br /> APPROX.BORING DEPTH PECIFICATIONS: J d d �, N✓Hf t e' e•.� <br /> 0 SOIL BORING 0 HAND AUGER BOLTED TRAFFIC BOX or Q STOVEPIPE <br /> :7_ =-f <br /> OTHER: CpT 0 OTHER— CONDUCTOR CASING PROPOSED? No (if YES,list specifications here):_ <br /> `COMMENTS: L pt- leAI56 t�S el <br /> O <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby <br /> Signed x certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> lations, <br /> Reguand all applicable Californian State Laws. <br /> Coun rdinances, Rules T elcompany / � ��2�T�/ T�� <br /> Date 7- 9�V3 <br /> Print Name �'^f �� DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: A ea <br /> Date Issued <br /> Application Accepted g1y Date? 7`(- �3 Final Inspection By <br /> GroutlnspectionBDate <br /> Destruction Inspection By r_p_ • . 6 S �V�'w <br /> COMMENTS!CONDITIONS:- Ks�•r'^^� <br /> ACCOUNTING ONLY: <br /> AID# cera <br /> RECD BY DATE .- PERMIT I SERVICE REQUEST# LINVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED S1 �� SR# C�3 S <br /> o sign permit_Encroachment doc_ <br /> c-, wr -WAIVER_ C-57 Letter of Authorization t <br />