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AeeAIS <br /> m o - WELL PERMIT APPLICATION FORM SITE <br /> E�� bl= EDD MITIGATION <br /> SAN JOAQUIN COUNTY v I -{- .UNIT IV <br /> DEC 2 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD);'' <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES µ (209)';468-3449 <br /> NON-REFUNDABLE'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;i 'bon is made in compliance with San <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This apP Assessor's <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental+Health Department. <br /> �T�City, .S`De*-wj Zip' Parcel# <br /> WELL Location�23 - �JO/�I 5`�Cross Street �"�. <br /> trop rstse5 STb�lGTD1� Zip!2gWPhonek� --R <br /> PROPERTY Ow <br /> F A Address 3 �. $Dll� City - - -~ -- <br /> v7 �� - <br /> � '7 C�'irvl t"if1 t les S�PlewrU�,Armjvlo <br /> Citi- ZipC-57 Contractor cess j 57V [�NLic#Phone# <br /> }_ R-L Dh3eLc-'� a Address_ WtoNT ��v — go4v S <br /> Consultant!Sub Contractor <br /> Towrish'sp Range t<'+ Section <br /> GIS Coordinates: <br /> X Y er <br /> WORK TO BE PERFORMED: /cif DESTRUCTION(choose type below) <br /> j]NEW WELL!BORING(CPT,GEOPROBE,IiYDROPUNCH,BAND-AUGER,OTHER") { ,F !ll��� OVER BORE <br />' []SOIL BORING# RES$URE GROUT <br /> U W ELL# ,1 !!l <br /> _ Grout Specifications: <br /> *Other: <br /> COMMENTS: <br /> I?� SSS be�IGG, $ Otlrir a r-t <br /> TYPE OF WELL 1� INSTALLATION TIPE CONSTRUCTION SPECIFICATIONS n <br /> MOMTORINC, [)HOLLOW STEM DIA.OF BOREHOLE' MULTIPLE CASWGS?p YES n NO WELL CASING DIA: <br /> VEXTRACTIO Z 11 AIR HAMMERIDRIVEN CASING THICKNESS" 'TYPE OF CASING: STEEL " PVC [)OTHER-. <br /> I]VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS 4 NOSE <br /> AIR SPARGE PUSH POINT GROUT SEAL PUMPED: n Yes !p No (NOTE: MAXLMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING Q HAND AUGER <br /> GROUT SPECIFICATIONS: ' '" " <br /> ]OTHER-_[] <br /> OTHER APPROX.BORING DEPTH n BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS- <br /> . <br />! NOTE: OFFS]TE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPEC'l IONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances R es and Regulations,and all applicable California State Laws. <br /> t sY G► ��� <br /> Signed x TitielCompany <br /> Date ' /Z Z <br /> i Print Name DEPARTMENT USE ONLY ` <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> 7 Areae <br /> �? ate Issued e ` �� <br /> Application Accepted By <br /> Grout Inspection By <br /> Date - F!nal Inspection By <br /> Destruction Inspection By ate <br /> { J J <br /> COMMENTS!CONDITIONS: <br /> G"a . f~ - <br /> FACCOUNTING ONLY: AID# cern <br /> CODES FEE INFO AMOUNTREMITTED CHECK# R C'D Y1 ',DATE PERMIT 1 SERVICEIRECIjUEST# INVOICE <br /> sp-� n. o 5"I i ��� IZZ SR# <br /> C-57 WC -WAIVE C-57 Letter of Autho za# to sign permit Encroachment doc <br /> 1./25/0 <br />