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WELL k _RMIT APPLICATION FO. -.JI SITE <br />SAN JOAQUIN COUNTY MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />JUN 1 0 2003 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />ENVIRONMENT HEALTH (209) 468-3449 <br />PERMIT/SERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application 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 />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />C [ 1� c Assessor's <br />WELL Location 3l�� ppi� J• (� �`` Gr< (Y C; Cross Street \% y City S"}QC,c ,'� Zip aG� Parcel# A <br />PROPERTY Owner VA D 9- �0 1 Address �. 0. 6C x (� d % City S64 ion Zip IS-'� I Phoney / - yt;;LS- - 3`1 a 1 <br />C-57 Contractor c,cje- Address 3 City Zip Lic# Phone# //(,��a3'"ii <br />Consultant/ Sub Cntr-Ja 1 Ge Address l—1 5kg-` J CityjT\ - Lic# Phone# ado- *-1"7- HCl o <br />NV, i <br />GIS Coordinates: X_ , Y Township Range Section <br />WORK TO BE PERFORMED: <br />'NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />/ 0 SOIL BORING # : y L t D'� 0 OVER -BORE <br />',WELL # - Mbc)-8, m t0 -9/ mt4)-j 2- 0 PRESSURE GROUT <br />*Other:Grout Specifications: <br />COMMENTSp <br />TYPE OF WELL <br />INSTALLATION TYPE <br />'(MONITORING <br />HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMERIDRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE / Ozone 0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER:____o <br />OTHER <br />Fe <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 8 ' MULTIPLE CASINGS?',JVULTI-LEVEL? a WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER:_ <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 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 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CA ING PROPOSED? ( if YES, list specifications here): <br />^� St'j• t� CLvx& fn C'.N, 4-cvs; A7 L--2 I � =A Ste- I I wor K F <br />(311 <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 certify t a <br />CountyO ft�'' Signed x /` rr� <br />Print Na t' ' -r 1 S <br />I have prepared this application and that the work will be done in accordance with San Joaquin <br />Rule and ulations, and all applicable California <br />tate Laws. C <br />Title/Company /-t imic ed <br />U 1h t r I r • � � L� t' Date 10 ,QAC Oq OO --- <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 3147 SOV+ja El Do ra d b 6+re 2J <br />WORK PLAN DATED: Aer) L 63. 2 Da Z p <br />Application Accepted By r Tit Date Issued J V 1 N T 2- D 0 3 Area 14 5 1 <br />Grout Inspection By_ ��t1 "Vrt". Date O Final Inspection By (,cA"nl ave Date ��_ <br />Destruction Inspection By 1 tDate '�� <br />COMMENTS/ CONDITIONS: �YIS�AIl�TI_nr, o-- QrounA Waley MWA MW-9,411dMW-12, <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERM ICE VEST # <br />INVOICE <br />3S6 1 <br />89.60 <br />99.00 <br />00 3 4-4'7 S <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign perm) en doc 8/29/02 <br />LA <br />