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PAYMENT WELL ERMIT APPLICATION F M SITE <br />RECEIVED MITIGATION <br />r�a� s 2003 SAN JOAQUIN COUNTY UNIT �� <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />SAN JOAQUIN COUNTY 304 E. Weber, Third Floor, Stockton, CA., 95202 -- <br />ENVIRONMENTAL 209 468-3449 <br />HEALTH DEPARTMENT <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 9-11115.3 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location t /�� /� ( ss Street ��`�y' �' vC P Q�Pascel#orsj) (�/�g7c) <br />PROPERTY Owner 1P26)`3 �/ f U/`R J C� City��p 75204one# (7 <br />C-57 Contractor �G Address 637 it � �Q �C_bic#10one# `/&7 G 30.p <br />Consultant / Sub Cntr ( l Address 1� City Lic# ! ` Phone# 1� <br />GIS Coordinates: <br />Y <br />WORK TO BE PERFORMED: <br />EW WELL / BORING (CPT, GEOPROBE, <br />Q]O LI BORING <br />W WELL # <br />*Other: <br />COMMENTS <br />Township <br />HYDROPUNCH, HAND -AUGER, OTHER-) <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING 0 HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR Q MUD ROTARY <br />Q AIR SPARGE / Ozone PUSH POINT <br />rl"SCIL BORING 0 HAND AUGER <br />Q OTHER:_________o OTHER <br />Range <br />Section <br />DESTRUCTION (choose type below) <br />Q OVER -BORE <br />0 PRESSURE GROUT <br />Grout Specifications: _ <br />CONSTRUCTION SPECIFICATIONS <br />/'/A <br />DIA. CF BOREHOLE, ?"41 lULTIPLE CASINGS? 0 MULTI-LEVEL? Ia WELL CASING DIA:___ <br />CASING THICKNESS N_^ TYPE OF CASING: Q STEEL 0 FVC 0 OTHER:-_ _ <br />DEPTH OF GROUT SEAL fRV <br />fes` TREMIE TYPE TO BE USED: '`RAUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes *No .(NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />GROUT SPECIFICATIONS: '5V' C(L_ _ <br />APPROX. BORING DEPTH -30 F� Q BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? �/ ;!�= (if YES, list specifications here): <br />S9� �� Q (� <br />*COMMENTS: � c,t�7 / s/ � L <br />v <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 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/s�. n <br />Signed x 64,1 C��^�/-l� Title/Compa(� \-2Cv1U <br />Print Name W / ` / - <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 1-7&(0 I'W l0 <br />WORK PLAN DATED: ) � ,,22> — TLT%Ak) / 5 <br />Date / &(3 <br />1 - w'j /-f <br />Application Accepted By Date Issued fit' /DO/ 01 -Area 7 <br />Grout Inspection By Date Final Inspection By - a fir Date I / <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE IT / ST # <br />INVOICE <br />a - <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encrbachment -doc 8/29/02 <br />