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N r • 13 , 2003 11 ; 21AM C JR EARTH TECHPiOLOGIES No . 3099 P , 3 / 6 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS -EHD) <br /> 304 E . Weber, Third Floor, Stockton , CA. , 95202 <br /> (209) 468.3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor Install the work described. This application is made in compliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Servlces, Environmental Health Clivision. <br /> ^ r� Assessor's <br /> WELL Location 6a.10 tt � • Cross Street P,rTcr QVe_. CitySt-oCJf..t-c., Zlp Parc/el# 081 -- 366-fit <br /> PROPERTY Owners City S1v,tvk v� ZIpR Phak(aggq°��'4'18+• 5$} 5 <br /> C-57 ContnaCtory'1' LQ �i � � <br /> [�Q �—.City�tCaLle± A Zip `7544t Lic#7aAj&LPhorT <br /> Consultant / Sub Conrractor(!OY\AYEOr{il F(f L' �p ddressjwr3 w&.. Loesr l-t✓r-City 5175cru� 1 Lic# Phone 2a4-651St' <br /> GIS Coordinates: X., Y_, . Township a }J Range E Sedion� (, <br /> WORK TO REPERFORMO: ESTRUCTION choose below) <br /> . [I NEW WELL / BORING ( CPT SOIL BOR NG uIIA <br /> DROPUNCH. HANG-AUGER, tlTHER') /"" U OVER-ORE <br /> 0 SELL # a PRESSURE GROUT <br /> "Other Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL $ INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS N <br /> ONITORING Mw HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? p YES 0 NO WELL CASING DIAL__._, <br /> a EXTRACTION 1] AIR HAMMER ORIVEN CASING THICKNESS TYPE OF CASING: 6 STEEL ('PVC a OTHER: <br /> Q VAPOR Ii MUD ROTARY DEPTH OF: GROUT SEAL TREMIE TYPE TO BE USED: [] AUGERS a HOSE <br /> ❑ AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: (I yes R No (NOTE; MAXIMUM FRE)"-FALL DEPTH IS 301 <br /> 0 SOIL BORING HAND AUGER GROUT SPECIFICATIONS:_ <br /> a OTHER,-.I] OTHER � APPROX. BORING DEPTH_ p BOLTED TRAFFtC BOX or I7 STOVE PIPE <br /> CONDUCTOR CASING PROPOS509 ( If YES, list speciflcaticns here): <br /> •COMMENTS: <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 /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations , and all applicable California State Laws. <br /> Signed x Title/Company <br /> Date <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED: C /' f j� <br /> Application Acrapied By _ ` ' U Date Issued i ? D v ea <br /> Grout InspeCUon By. <br /> Date Final Inspectian By Da <br /> Destructlon Inspection By Date <br /> COMMENTS ! CONDITIONS: <br /> ACCCUNTINGCNLY7 AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC' eY DATE PERMFr / SERVICE REQUEST # INVOICE <br />