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WEL�` IJERMIT APPLICATION M- M SITE <br /> �,,�� i��<<��C' MITIGATION <br /> L <br /> ,SAN JOAQUIN COUNTY UNIT IV <br /> JUN 1 7 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRIJNIVIEN i HEALTH (209) 468-3449 <br /> PERMIT/SERVICES <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 Titter Cha ter 9-1115.3 and the Standards of fan Joaquin County Environmental Health Department. ^7 <br /> �. i►!� UY�'E `oftx k- e 1 Assessor's /3: �� C <br /> WELL Location. n_ _ Cross Street -city. 19iV Zip Parcel# <br /> PROPERTY Owner `/jl(/n7' ?hX} bn Address 22 E•"L°l X350 city. /U Z,pPhone# <br /> C-57 Contractor&(.C7d4?d(7P�7 G�i►�U/r/n. Address F37 S" t4C- city Zip G57/5 Lic#6,Q0337Phone# ye � <br /> Consultant/Sub Cntr Address City Lic# Phone# <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 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 /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE /-1-- MULTIPLE CASINGS?[]MULTI-LEVEL?0 WELL CASING DIA: <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 f (NOT <br /> TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> f1 AIR SPARGE/Ozone PUSH POINT GROUT SEAL PUMPED: 0 Ye, o(N T MAXIMUM FREE-FALL DEPTH IS 30') <br /> �},f.S0 OIL BORING HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: fI OTHER APPROX.BORING DEPTH Z 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: <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 appli ation and that the work will be done in accordance with San.Joaquin <br /> County Or es, I Regulation nd all applicable California StaterLaws. <br /> Signed x Title/Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: l <br /> Application Accepted By. ,�1 W Date Issued 73 , ?()(9 <br /> Ar a <br /> Grout Inspection By ate (10 4a&OFinal Inspection B ate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> r <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# ffCgBY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 01 C6 [hb 3 <br /> C-57 WC -WAIVER C-57 Letter of Autho ' at' Si n permit Encroachment doc 8/29/02 <br />