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r WELL -ERMIT APPLICATION Fr - M <br />flEUD, <br />SAN JOAQUIN COUNTY <br />JIIL `Z 1 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />ECJ\lIRO(�PJ1Ei'�1 �'EH�i (209) 468-3449 <br />p R,v iT;SERVICES <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <br />\oplication is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br />oaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />///j Assessor's <br />VELL Location ' 7((� l/�% %(JSE'7,�lT� Cross Street 7 fes/ / City r-�--7�p Parcel# Z21 ��U-s 5 <br />'ROPERTYOwn/e/r t/� vin' G� 1�1E��AdQdress �� I?JZ ^/-�'-�� " �i� City ��,lC4y�(LC�i- Zip %Tq�Phone# 2 Z � 31 Z <br />57 ContraCor (� j�i17` lJJ f�G/�� Address 032 2dW �t� /� /�� City 11C9C�11 Wzip 3 Lim �t IS�X Phone# abs - ��00 �2 <br />:onsuitant / Sub Cntr (I �(iv2E ' (7�� Addresses -37 JG1Gw / "-ti'�`C� City -6- �/\_ Lic# Phone# <br />;IS Coordinates: X , Y Township Range Section <br />ICRK TO BE PERFORMED: <br />NEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER-80RE <br />D WELL # RESSURE GROUT <br />7ther: <br />OMMENTS <br />YPE OF WELL INSTALLATION TYPE <br />MONITORING 0 HOLLOW STEM <br />EXTRACTION 0 AIR HAMMER/DRIVEN <br />VAPOR 0 MUD ROTARY <br />AIR SPARGE / Ozone 0 PUSH POINT <br />SOIL BORING 0 HAND AUGER <br />OTHER: n OTHER <br />:OMM <br />Grout Specifications: 2 -�; 1� <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BCREHOLE X I MULTIPLE CASINGS? 0 MULTI-LEVEL? fj WELL CASING DIA:__ <br />CASING THICKNESS Gi V0 TYPE OF CASING: 0 STEEL 0 FVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: //MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH 2- j 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? N)I--( if YES, list specifications here): <br />rrjrrf s5V r c nAy o,M_ IN <br />. <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 />lereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />ounty Or noes, Pules Regulations, and all applicable California State Laws. <br />3ned x Title/Company _%//7G/lQc_G' <br />int Name Date T/% l/ <br />DEPARTMENT USE ONLY <br />TE MAP IN UNIT IV FILE, ADDRESS: �� b� �• �/pS,elMl ��11 F, {tila+ntteo� (�'4 �i(� <br />ORK PLAN DATED: <br />plication Accepted <br />out Inspection By_ <br />�struction Insoecto <br />)MMENTS / CONDITIONS: <br />Date Issued 2-1 Area <br />ate as ' p Final Inspection By Date 2S� <br />Date -4' Z�_)CP 3 <br />\CCOUNMNG ONLY: <br />AID# <br />'E CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />3 0 <br />�o ,oU <br />I�`156 <br />zl a3 <br />3 "-14,'/11 <br />-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br />Encroachment doc 8/29/02 <br />�kk '0 Cody <br />