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WELL PERMIT APPLICATION FORM SITE <br /> rEQ(Et ;��EE) MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> JUN 17 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIROrWENT 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 Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ��// '�/1 � Assessors �Z <br /> WELL Location 7Ze Xr 4§W1_s1'A1 S� Cross Street 4iWoeAt City_Sz4d Zip Parcel# <br /> PROPERTY OwnerrJ /1'�pQ/4w"Eo, "ss t1W k. �J�W_/hJ S7— City�,��Zip Phone# <br /> C-57 Contractor ft(((lcl/1/Q/ l7lc+f� Address,07J e-w 2 City Zip S�/ Lic /� hone#T��y 7%dC <br /> Consultant/Sub Cntr 3&ztj/[.r 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# Jr 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/-5_• MULTIPLE CASINGS?0 MULTI-LEVEL?0 WELL CASING DIA: W4_ <br /> p EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 414- TYPE OF CASING: []STEEL 0 PVC []OTHER: A1,4- <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL A_5"' TREMIE TYPE TO BE USED: ,0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/Ozone PUSH POINT GROUT SEAL PUMPED: []Yes ro (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 44 l e_1 <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH ZSR 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? A1+ (if YES,list specifications here): <br /> 'COMMENTS: �l[ BdlLf.[�i S 6t/L <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 /> hereby certify that I have prepared thisa plication and that the work will be done in accordance with San Joaquin <br /> County Or nce Rule nd Re all applicable California <br /> /Stte Laws. <br /> Signed x Title/Company ///7 <br /> Print Name <' Dated <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued ZoAr a <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> g�,w IX75�- ,' 6 13 03 sm V9 <br /> C-57 WC -WAIVER_ C-57 Letter of Authori io o sign permit Encroachment doc 8/29/02 <br />