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WELL. fi—IRMIT APPLICATION FG_ _,VI <br />PIECRIWEDi SAN JOAQUIN COUNTY <br />JUL 14 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />ENVIRONMENT HEALTH (209) 468-3449 <br />PERMIT/SERVICF� <br />SITE <br />MITIGATION <br />UNIT IV <br />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 />Z�'4 2 a- ty��GL T f S Assessor's <br />WELL Location 1T� V-94&1�(� ,G( Cross Street 1� Ci / ` 7, (Zip 5 Parcel# / 33 x <br />PROPERTY Owner��t (r f2Ar Address 2/ iG (/1 I�}C�/� � /?E/Lf�/ City J�IX (L/�►`1 Zip?S' Phon 2�r� � �/J <br />C-57 Contractor IPL 7 947- r Address l5 f r`�P� d Sl City 0 ✓� Zip % Licr��. Phone# )( (v / 1r' <br />Consultant/ Sub CntrA4✓Qp1(ip GGl:��f/ ''SIN/aiAddress$5 % St1l_�w c2 City L O Li �L2� Phone�20 X�y <br />GIS Coordinates: X , Y , Township Range <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />0 SOIL BORING # <br />0 WELL # <br />*Other: <br />COMMENTS <br />Grout Specifications: <br />Section <br />DESTRUCTION (choose type below) <br />0 OVER -BORE <br />a PRESSURE GROUT <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />MONITORING <br />1,'HOLLOW STEM <br />DIA. OF BOREHOLE eMULTIPLE CASINGS? 0 MULTI-LEVEL?� WELL CASING DIA:_Z- <br />0 EXTRACTION <br />, IR HAMMER/DRIVEN CASING THICKNESS4(a Vz> TYPE OF CASING: 0 STEEL A \PVC 0 OTHER: <br />0 VAPOR <br />o MUD ROTARY <br />DEPTH OF GROUT SEAL SG TREMIE TYPE TO BE USED: VAUGERS 0 HOSE <br />p AIR SPARGE / Ozone p PUSH POINT <br />GROUT SEAL PUMPED:Yes p No (NOTE: MAXIMU FREE -FALL DEPTH IS 30') <br />i] SOIL BORING <br />p HAND AUGER <br />GROUT SPECIFICATIONS: �(-' l,:k ,F <br />a OTHER: <br />1] OTHER <br />APPROX. BORING DEPTH�( LTEDkAFFICBOX or U STOVE PIPE <br />CONDUCTOR C SING PROPOSED? O ( if YES, list specifications here): <br />*COMMENTS: O/V <br />[�(i l �D�T /1y11,((7Ug/ <br />i ,- �6L <br />I herebi <br />County <br />Signed x_ <br />Print Nam <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 />that I hiave prepared this application and that the work will be done in accordance with San Joaquin <br />ices, R�les and Regulations, and all applicable California State Laws. <br />L r(.1'' -1-1,r\ r v. / <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted E <br />Grout Inspection By <br />Destruction Inspection <br />COMMENTS / <br />DEPARTMENT USE ONLY <br />Inspection By <br />y, - Area <br />ACCOUNTING ONLY: <br />AID# <br />o 0 �-A <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED CHECK # <br />RE -D BY <br />DAT <br />PERMIT/ SERVICE REQUEST # <br />INVOICE <br />.3501 <br />1 5q. 0CA 05' <br />: c1 -o <br />3`- <br />C-57 WC -WAIVER C-57 Letter of Author&t on Sin permit Encroachment doc_ 8/29/02 <br />7 <br />-4- <br />CF <br />0 <br />