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4 <br />EvavEr WELL rERMIT APPLICATION ROM <br />FEB 2 4 2003 SAN JOAQUIN COUNTY <br />ENVIRUNMEN I HEALTH ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />PERMIT/SERVICES 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br /> <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br /> <br />C-57 Contractor WeS HA-2_ Oct+ Addres 3 Fri—Z.,,,AZil-----4-City <br />PROPERTY Owner 6 5-4S,c4P-4A Address q 2--- .6z--7-492$ S 46ity .574t f--4,sti zip 1 SX3 Phone# ?2 7 g 3 7 (t <br />Zip ?5-7Y4ic it779 Ph one#4&' eV 72•7‘c, <br />Consultant/Sub Cntr 13cc-- .-- Address 6 7 5 LGt-tA) City ...A0----7Q Lic# Phone# <br />GIS Coordinates: X Y , Township Range Section <br />WORK TO BE PERFORMED: <br />JRNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />El SOIL BORING # <br />I] OVER-BORE <br />WELL # 1 p <br />0 PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS <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 J aquin County Environmental Health Department. <br />Assessor's <br />WELL Location j <br />4A d <br />)I e)C- <br /> <br />5--- Cross Street ti(- k_Cd)7t City 5/De-MI Zip4S-2-.6 ( Parcel# <br />TYPE OF WELL INSTALLATION TYPE <br />AONITORING -11OLLOW STEM <br />EXTRACTION AIR HAMMER/DRIVEN <br />VAPOR l] MUD ROTARY <br />fl AIR SPARGE / Ozone ['PUSH POINT <br />fl SOIL BORING fl HAND AUGER <br />a OTHER: U OTHER <br />*COMMENTS: <br /> tvl <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE g ,:ick MULTIPLE CASINGS? U MULTI-LEVEL? [i WELL CASING DIA: ‘- <br />CASING THICKNESS TYPE OF CASING: U STEEL rfrrVC U OTHER: <br />DEPTH OF GROUT SEAL 60 - fig 1 1/(REMIE TYPE TO BE USED: ,,flA-UGERS U HOSE <br />GROUT SEAL PUMPED: (nes (w) (N9TE: MAXIMUM FREE-FALL DEPTH 18 30') <br />GROUT SPECIFICATIONS: pae. <br />APPROX. BORING DEPTH -2 -C Fee--11- LTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />5(46-d-FAc //i <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 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 Laws. <br />-6 1=1; Signed x Title/Company - (27E /— <br />Ii I/- L (-FF Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: (I 1/0 es"-- S <br />ac7L96e 4rea/q <br />Date Issued <br />Final Inspection By Date <br />Print Name <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS. <br />ACCOUNTING ONLY: AID# <br />; <br />6X1203 ?194 / / <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC' DATE PER' * V CE REQUEST # INVOICE <br />5-12 I s q ° til /1 A 21 Z12103 12-4 3 C7(.0 <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of AuthorizatronV sign peplmit Encroachment doc <br /> <br />8/29/02 <br />