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WELL. dERMIT APPLICATION FC _BVI SITE — <br />RECENEDD . SAN JOAQUIN COUNTY MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />JUL 14 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 />O� 7 Assessors <br />WELL Location AAUSO'� kliiC Cross Street r) f� 'N T Ci -7 - � Zip rG Parcel# <br />T" �r S "Ck-Tc..! 3.j Aj. CL bic17(OZ7e q 7 c <br />PROPERTY Owner /�a aSntGt cap -ii r�� li���lLL Address �l A 2� v City S%L�(Grv�/ Zip �r�4 L Phone# <br />�/ t, Wo p Ce tt�� <br />C-57 ContraCNAZ <br />.orlt ,f %t T Address -523 � 6L -z rbp (a 11� �City(� G✓� Zip �57yZ Lic#0/!>Y� Phone& —,9' 7L%( <br />/ , a' %9 t� �- 7�/ccs E <br />Consultant /Sub Cntr��1/.�,t((,fl� c.�fcC,�lv/�iti,��¢:�f�4ddress 7 � � � Ci � 1l Lic# LZ Phon <br />GIS Coordinates: X Y Township Range Section <br />W RK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) ]3 DESTRUCTION (choose type beicw) <br />0 SOIL BORING # 0 OVER -BORE <br />0 WELL # 0 PRESSURE GROUT <br />`Other: Grout Specifications: _ <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING j� F'iOLLOW STEM DIA. OF BOREHOLE ' MULTIPLE CASINGS? 0 MULTI-LEVEL? aWELL CASING DIA: r __ <br />p EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS5�'bI TYPE OF CASING: 0 STEEL ;WPVC 0 OTHER:__ <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 10CUGERS 0 HOSE <br />a AIR SPARGE / Ozone 0 PUSH POINT GROUT SEAL PUMPED: XYes 0 No (NOTE: MAXIMU FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br />Q OTHER: 0 OTHER APPROX. BORING DEPTH OLTED FFIC BOX or O STOVE PIPE <br />CONDUCTOR CASING PROPOSED?_kL_ (if YES, list specifications here): <br />*COMMENTS: (�/-(�- �� /N, W <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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br />County,din es, uses and Regulations, and all applicable California State Laws. / [ <br />Signedx \ ))¢�J� �_ Title/Company Sr-4cr (� /&Zu-r, S l��V&L-� <br />Print Name rC L •`� <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted <br />DEPARTMENT USE ONLY <br />l <br />Date Issued <br />Grout Inspection By v Vy Date Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />i <br />Date 0`�—'/ `0 <br />,-q(- <br />ACCOUNTING <br />qL <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNTREMITTED <br />CHECK # <br />REC'D Y <br />DATE <br />PERMIT[// SERVICE REQUEST # <br />INVOICE <br />� 0 � <br />(J • Od <br />V � <br />>� <br />�- 2 <br />C-57 WC -WAIVER C-57 Letter of Authidri toloo sign permitt Encroachment doc 8/29/02 <br />S 7, �60 �L� ' <br />