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7 <br /> E [E \�i�E WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> JUN 17 2003 SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> ENVIROtWENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 468-3449 <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 /> may/ Assessors <br /> WELL Location��/�' ,f��I�J�Y�Is U cS�Cross Street City Zip Parcel# <br /> PROPERTY Owner zU 07 ,�7`rZ 4� Add�reess / City. Zip Phone# <br /> C-57 ContractorkI,.W�/6&067 LAddress l 1 Sr/`A0 AUe/ City_,5��Zip .1/ Lic#hL63 hone# 4,7 <br /> Consultant/Sub Cntr `�� Address City Lic# Phone# <br /> GIS Coordinates:X 'y Township Range Section <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL/BORING(CPT,GEOPROBE,HYD PUNCH,HAND-AUGER,OTHER') p DESTRUCTION(choose type below) <br /> XSOIL BORING# a OVER-BORE <br /> a WELL# a PRESSURE GROUT <br /> "Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> G MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE /,_� "'MULTIPLE CASINGS? MULTI-LEVEL?0 WELL CASING DIA: <br /> p EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS IVA TYPE OF CASING: o STEEL []PVC a OTHER:�� <br /> B VAPOR o MUD ROTARY DEPTH OF GROUT SEAL 2 S TREMIE TYPE TO BE USED: .Q AUGERS a HOSE <br /> G AIR SPARGE/OZonexPUSH POINT GROUT SEAL PUMPED: []Yes [Olo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING aHAND AUGER GROUT SPECIFICATIONS: f'/�4.LTL/F <br /> 0 OTHER:_H OTHER APPROX.BORING DEPTH �rn� []BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? i• (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 application and that the work will be done in accordance with San Joaquin <br /> County Ordi ces ules and Regulati ns, and all applicable California State Laws. <br /> Signed x /1 Title/Company <br /> Print Name '-Pit /� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted Bye Date Issued �� Area, <br /> Grout Inspection By Date Final Inspection By fV ate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: Y <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNTT REEMITrT�E,,ID CHECK# RECD Y TE PERMIT/SERVICE REQUEST# INVOICE <br /> �� <br /> C-57 WC -WAIVER C-57 Letter of Authorizntio si pe t Encroachment doc 8/29/02 <br />