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WELL .- tERMIT APPLICATION F&M SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) jo <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 "�I� y J <br /> (209) 468-3449 APR 2 9 2003 <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 applicatio,51 h�N4164ii lItklSan <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Departr MIT/5EF,,VICF) <br /> f /� �n l[..oI Assessor's <br /> WELL Location G Boyl . Y 180A / Cross Street fT City ff Zip Parcel#0Q6i^GS-23 <br /> PROPERTY OwnerKbCIM O -yyn& Address 411?- j)e,1,6 .rj,. City S GIA Zip Phone#`?y$-`1 q l°2 <br /> x.V+restv1red Pcr' 13.(,.Z Scut SooIrnu Co Watt S}cuu 5 <br /> C-57 Contractor Address City Zip Lic# Phone# `�� <br /> Consultant/Sub Contractor n.Lr� Pr, Address 011lin 4 m S+ city_f•$�Lic# Phone#_R�--ik <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PE MED: <br /> 0 NEW WELL/ ORING)CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER, THER* 0 DESTRUCTION(choose type below) <br /> SOIL BORING# SPI +t% ut k S P 10 0 OVER-BORE <br /> 0 WELL# p D PRESSURE GROUT <br /> *Other: Grout Specifications:�i� e,Q,�yfw.�'- <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 3/u LMULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS pTYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1 C%5-tft TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 'SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes )<No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> IL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Kya.+ rPV►t <br /> 0 OTHER: BOTHERV=dk oAypmLLAPPROX.BORING DEPTH) L 9-STtCl" 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 application and that the work will be done in accordance with San Joaquin <br /> County Ord' anc ules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Name eAV3 _ C',xt\ Date 2r 0 3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted B Date Issued S o3 Area % <br /> Grout Inspection By —Date// Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: U)D( 7 <br /> OUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> metol s-,- X11- l?'� Y� 5 1 03SR# 4d 3� �� <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br />