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ORIGINAL <br />WELL PERMIT APPLICATION FORM SITE <br />llnn�� V SAN JOAQUIN COUNTY MITIGATION <br />4 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />NOV 2 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />EN(209) 468-3449 <br />PEI RMMSERVICES UV <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 />L / _ / /� Assessors <br />WELL Location 7 �� 4,a-/V!2r CCS, !' Cross Street f Kwt%1/!L City ��t� Zip 4T& ' Parcel# <br />PROPERTY Owner Address City Zip Phone# <br />C-57 Contractor Address UCCity 1-5 Zip y�/ Lic#LPhone# i/( %/I "r%/�`� <br />Consultant / Sup Cntr L>.� Address ��?r 2t City .718�� LiC# �Y 51 Phone# ��`i" Z 3� <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL I BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') p DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />O'Other GROUT SPECIFICATIONS <br />COMMENTS: <br />4� <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS O <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: r� v <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL s TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS _W eA'T+ <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 2_- 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, F lep,and Regulations, and all applicable California State Laws. <br />Signed Vim- Title/Company <br />Print Name V.C� C ;' ?, <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: Z0i?/ C.r/Gli1L Ilee <br />WORK PLAN DATED: //-ZZ-a3 <br />Application Accepted By <br />Grout Inspection By_ <br />Destruction Inspection B <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />Date <br />FAC# <br />Inspection By <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE <br />.3502. WA i - Ig55 l( -z` <br />C-57 WC ✓-WAIVER_ C-57 Letter of Authorization to sign permit <br />PERMIT / SERVICE REQUES14 <br />SR# Q p� <br />Encroachment doc <br />– ? -2 —0 <br />INVOICE <br />9/30/02 <br />