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10/23/2003 08:14 2094683433 FIFTH FLOOR PAGE 04 <br />WELL PERMIT APPLICATION FORM <br />OCT 2 9 2003 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (F -HD) <br />ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />PERMIT/SERVICES (209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />NONREFUNDABLE PERMIT EXPIRES 1 YEA FROM DATE ISSUE PP is mat�aace with San <br />Application is hereby made to San Joaquin County for a permit to Construct and/or install the work described. This a Iication de in comp' <br />Joaquin County Development Title, Chapter 9-1115.3 and theStandards �ofof San Joaquin County Environmental Health Department. Assessor's <br />rip <br />WELL t ocatiom cCity - 2 <br />ross Street <br />PROPERIY Owne <br />C-57contractorAddress <br />City 0, S&4 I Phone#42Qi )313 <br />Address 1k00 50_' S� Cirye,� ��P�Y�!--�� L10$PnoneR�S10�.�33-�/S7S <br />ac¢S �.c.n �w�� c� Phone# 'f )SS/ -7212 <br />��' ,S�AddressrltS7� ��—CitY.�s��,�Lic#^,� <br />Consultant l Sub Contractor F-r,,t��o �.,.� L �c h _ <br />.t JeAkafFCCkLt.�ws� ,Township Range Section <br />GIS Coordinates: X U Y— <br />WORK TO BE PERFORMEO: p DESTRUCTION (goose type below) <br />EW WELL! BORIN (CPT, GEOPROSE �YDROPUN_. . HAND -AUGER, OTHER') 13 OVER -SORE <br />�.g01t BORING # .Z . I o�'A 13 PRESSURE GROUT <br />0 W ELL # Grout Specifications: <br />'Other: <br />COMMENTS: <br />rYpE^ OFWELL tNSTALLATION TYPE CONSTRUCTION SPECIFICATIONS O WELL CASING DIA: <br />0 MONITORING Q HOLLOW STEM DIA. IN BOREHOLE ^ 2 MULTIPLE or CASING. 0 STESINGS? BYES � O PVC Q OTHER:� <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_ n//a�� <br />p VAPOR a MUD ROTARY DEPTH OF GROUT SEAL:i, -%o e TREMIE TYPE TO M USED: p AUGERS p HOSE 0 AIR SPARGE jt4SH POINT GROUT SEAL PUNIPED: ees ONO (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />R,nIL BORING Q HAND AUGrR GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH '� 0 BOLTED TRAFFIC BOX or p STOVE PIPE <br />p OTHER;_V OTHER, CONDUCTOR CASING PROPOSED. (if YES- list specifications here): <br />'COMMENTS: <br />NOTE: OFFSITE BORINGS REQUiRQUSGN AAVESS OANCE FOR OAC ALL �gUIRED INSPECTPERMITS. <br />10NS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HR <br />I hereby certify that 1 have prepared this application and that the work will.be done in accordance with San Joaquin <br />County Ordinanc sand Regulations, and all applicable California State Laws. <br />Muelcompany_(�)Ta <br />Signed z <br />�CT y1^ ��� Date p . <br />Print Name unr=ondTIUFNT l{SF ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED' <br />Date IssueArea� <br />Application Accepted By Date---- <br />Grout Inspection By <br />Date I U Final inspection By <br />Date <br />Destruction Inspection By r r _ ► ' ..e <br />COMMENTS f CONDITIONS: cob <br />ACCOUNTING ONLY: AIDS <br />PE CODES FEE INFO AMOUNTREMITTED CHECK # REC'D pY DATE PERMfT !SER CE iiE VEST ii INVOICE <br />�qo( (67SD l ►1 G 63 SR#OC�3�`(s <br />C-57 WCC WAIVER C-57 Letter of Authorization to sign perm Encroachment <br />