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r� WELL PERMIT APPLICATION FORM SITE <br /> iRECE EV MITIGATION <br /> 1N SAN JOAQUIN COL NTY UNIT IV <br /> SES 1 9 2003_ t ENVIRONMENTAL HEALTH DE ARTMENT (EHD) <br /> ENT HEA1-�H 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENViRO�M r_ (209) 468-3AAO <br /> .PERMITISERVISES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 FROM DATE ISSUED <br /> application is hereby made to San Joaquin County for a permit to construct and/or install a work described. This application is made in compliance with San <br /> oaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin unty Environmental Health Department ' <br /> ,/ Assessors I63•z3a 1 <br /> �VELL Location l� ..1 1 Q T `Cross Street C€ty Zip Parcel# <br /> ,tl� - i ; <br /> 'ROPERTYOwner��a „.Addresss 1P,0 City.S�ZtkQb� Zipq�;&0} Phone#i,�� <br /> -57 Contractor f Ad { <br /> dress IQ1t�� CriTC€ �, _Z1pc ?one# r t I <br /> t <br /> :onsuttarrt/Sub CntrAddress r I C City Lick t Phone(# <br /> 9 , <br /> SIS Coordinates:X Y Township: " Range a Section <br /> VORK TO BE PERFORMED: , <br /> ]NEW WELL/BORING(CPT GEOPROBE,HYDROPUNCH;RANI]-AUGER.OTHER] q DESTRUCTION (choose type below) <br /> OIL BORING# [}OVER-BORE <br /> [] ELL# 0 PRESSURE GROUT i <br /> Other: Grout Spe ifications: <br /> :OMMENTS <br /> I <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I MONITORING i]HOLLOW STEM DIA.OF BOREHOL: , '�MULTIPLE CASINGS?o MULTI-LEVEL?a WELL CASING DIA: <br /> I EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS ftj TYPE OF CASING: [j S"!tEL 13PVC O OTHER: <br /> ]VAPOR {]MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED. 1]AUGERS Q HOSE <br /> ]AIR SPARGE/Ozone�PUSH POINT GROUT SEAL PUMPED: a Yes [i No`(NOTE: MAXIMUM FREE-FALL,DEPTH IS 30') <br /> SOIL BORING HAND AUGER GROUT SPECIFICATIONS: <br /> I OTHER: _D OTHER APPROX.BORING DEPTH O [i BOLTED TRAFFIC BOX or I]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?— (if YES,I'Ist specifications herey <br /> 'COMMENTS, <br /> NOTE: 'OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN AE VANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby certify that I have prepared this application and that the wi irk will be done in accordance with San Joaquin j <br /> ounty antes, Rules and Reg s, a all applicable California State a s. <br /> aigned x Comp y B <br /> ?tint Nacre V 1 Date G <br /> _ <br /> DEPARTMENT.USE. ONLY <br /> SITE MAP IN UNIT IV FILE,ADDR SS: o <br /> WORK PLAN DATED' r ' <br /> Application Accepted By m r Date Issued d Area O <br /> Grout inspection By <br /> Date final In pectlon By 6'b <br /> Destruction Inspection By Data <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY:' AID# ^ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATF PERMIT I SERVICE REQUEST# . INVOICEx <br /> moo 3591 <br /> C-57WC -WAIVER C-57 Letter o Authorization to ig permit Ems# doc 8/24/02 <br /> dccaAo-oti <br />