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[-E7 <br />MAR 27 2003 <br />WELL dERMIT APPLICAMN R.,RM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />.NvikuNIMENT HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Applica'tioipiEpeWftliaaSt Joaquin County for a permit to construct and/or 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 Environmental Health Department. <br /> <br />23 / zipc75270s. PAasrsceettsisor's <br />WELL Location --: /44/c- <br />.4, <br />16--7 ea ie--;f2 Cross Street —Cif irb City --S7.711t da/2•) <br />- :1-414b6 --- 6 , PROPERTY Owner al V ( 3% 4 a_ Address.j 32 ii4 14eleka --.'d citycYze id41 zip q52.32ahone# '17 <br />C-57 Contractor/1 --(>2CflY"-- Ns[16 Address:34.32 (..9112C,4 V.` City• e / ZipC 7V_Lic4 Pang 637 — //i4 i <br />Consultant/Sub Cntr /)-(7 6 Address g _47 1)a ,-) city -CI-4A) Licit phcieif 2 96 7 /JO 6:) <br />GIS Coordinates: X Y , Township Range Section <br />WORK TO BE PERFORMED: <br />A-NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />0 SOIL BORING # a OVER-BORE <br />):1.10VELL # 8.X e_. 0 PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS <br />TYPE OF WELL <br />,211/-ONITORING <br />0 EXTRACTION <br />VAPOR UMUD ROTARY <br />0 AIR SPARGE / Ozone 0 PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />OTHER: 0 OTHER <br />*COMMENTS:eA4-I-A-OL /If <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE /e2 11V1TIPLE CASINGS? 0 MULTI-LEVEL? El WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL .'VC 0 OTHER: <br />DEPTH OF GROUT SEAL Fa" TREMIE TYPE TO BE USED: „frAUGERS 0 HOSE <br />GROUT SEAL PUMPED: U Yes 0 No (NOT: MAXIMUM FREE -FALL DEDTH IS 30') <br />GROUT SPECIFICATIONS: P-04-4 <br />APPROX. BORING DEPTH g3e7 R6OLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />INSTALLATION TYPE <br />OLLOW STEM <br />0 AIR HAMMER/DRIVEN <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 I 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 Law p. , <br />Print Name Pr/r 1 ./Z-/ i 4 yl.,_ Date 5 - <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By ii.....)-e-A- Date Issued 3/ / /0 7 Area 99 2 /t of <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By • Date <br />COMMENTS/CONDITIONS LW Site — 0 1^-) :7'''C <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />./E53/c.-,2-. /r.*Li 3///4.3 <br />Signed x <br />(1/11 or Title/Company <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc <br /> <br />8/29/02 <br />