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of <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />RE -'COVED ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />JUN 19 2003 (209) 468-3449 <br />0 RIGtM <br />SITE <br />MITIGATION <br />UNIT IV <br />o ti Ia.uJ io/1 i <br />_NVl UNNI i,f f HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Applicatioy fan Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br />Joaquin Co -ale v m=t Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />-� CLv:)t{� 0v6 +r� C vnciv Assessor's <br />WELLLocation �( l Cross Street FP ✓an/l)yfVCity TACK T^ 1Zip �iaLi Parcel#_ <br />civa <br />PROPERTY Owner � �; N/J 19 A K F % Address Q I51 C., n441-irR %v a - ty S %p( tC 7-a,,/ Zip l Phone l�ot� 'I b�' 71-5 <br />C;r�jeR/�>v�h� 957yL <br />G 57 Contractor C,)S'CgDL Ohr/�r'nAddress 3(i3 Z QMf� Ciry a FZ0;3vri Zip Lic# / S/ Phone#�11b 65h/10 <br />Consultant /Sub Cntr_ . � , F Address �3 % sf�if� W Ru CityS l C�KTDA Lic#,6_L" 2Phone#(F,0C. <br />GIS Coordinates: X <br />, Y <br />Township Range Section <br />PE CODES <br />WORK TC. BE PERFORMED: <br />REMITTED <br />CHECK # <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, <br />HANG -AUGER, OTHER*) Q DESTRUCTION (choose type below) <br />P ST # <br />INVOICE <br />Q SOIL BORING # <br />Q OVER -BORE <br />Z <br />WELL #_ <br />Q PRESSURE GROUT <br />*Other: <br />Grout Specifications: <br />COMMENTS <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS-AM <br />Q, <br />ONITORING <br />Q RACTION <br />'/ `` 'B FOLLOW STEM <br />Q AIR HAMMER/DRIVEN <br />DIA. OF BOREHOLES h MULTIPLE CASINGS?�MULTl-LEVEL? 1] WELL CASING DIA: <br />S�hec�v)C <br />CASING THICKNESS � e TYPE OF CASING: Q STEEL XPVC Q OTHER: <br />Q VAPOR <br />Q MUD ROTARY <br />DEPTH OF GROUT SEAL J TREMIE TYPE TO BE USED: Q AUGERS HOSE <br />Q AIR SPARGE / Ozone Q PUSH POINT <br />GROUT SEAL PUMPED: XYes Q No (NOTE:: MAXIMUM FREE -FALL DEPTH IS 30') <br />Q SOIL BORING <br />Q HAND AUGER <br />GROUT SPECIFICATIONS:_ <br />Q OTHER:_0 <br />OTHER <br />APPROX. BORING DEPTH I L `> ` ')BOL Ei D TRAFFIC BOX or Q STOVE PIPE <br />CONDUCTORCCASI PROPOS (if YES, list specifications here): <br />*COMMENTS: <br />/An1GVN0 <br />V,-ioAr, bly Tlc CA i)prl) l <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 Or nances, Rules and Re ulations, and all applicable CaliforniState Laws. <br />Signedx +/� \ Title/Company / /11���� <br />Print Name V &MID rN J. C V��� Date 0b C G 3 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, A/D�pZ <br />RESS: l� <br />WORK PLAN DATED: `�` ''D 2 -- <br />Application Accepted By Date Issued 4 f Area <br />Grout Inspection By Date Final Inspection By Date l7i�P'3 <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFOAMOUNT <br />REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />P ST # <br />INVOICE <br />SO <br />%VV <br />Z <br />b -IR- 2- <br />C-57 ✓ WC / -WAIVER C-57 Letter of Authorization to sign permit achment doc`� 8/29/02 <br />i:: <br />