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I <br /> r <br /> nLE44" <br /> WELL PERMIT APPLICATION FO � SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHE) <br /> 304 E. Weber, Third Floor, Sta'ckton, CA., 95202 <br /> (209) 468-3449 APR 1 8 2003 <br /> E NON-REFUNDABLE PERMIT.I=XPIRES 1 YEAR FROM DATE ISSUE P j04 � � n t n <br /> Application is hereby-made to San Joaquin Cauntyfor a permit to construct andlor instal!the work described. This a plication is r�i{ MPTQ� jn f E t l f <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department Assesso s <br /> WELL Location L� Crass Street&►,IIr f L( City 6i L-7Z�L Zp <br /> 1G( Parcel# <br /> PROPERTY Owner Address ll j{l I���✓ City lu �(� ziPhone# <br /> C-57 Contractor�l(1CAddress/d�l� /Yf flJ} v Gni City—Zip/�P7Gt <br /> I 1c 37 AW 9Z <br /> —Ci f 7 Lic# ZZ7 PhoneE� Zc� '- d,;r <br /> Consultant t Sub Cntr ci a Address <br /> G15 Coordinates_X Y ,Township Range <br /> Section l <br /> WORK ERFORMED: DESTRUCTION (choose type below) <br /> E WELL BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) � [I OVER-BORE <br /> a SOIL BORING# <br /> DWELL#�(N' t.�L ` PRESSURE GROUT <br /> "0ther: Grout Specifications <br /> COL:MENTS <br /> TYPE.OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> XW16NITORINGHOLLOW STEM OIA'OF BOREHOLE T•Z MULTIPLE CASINGS?[I MULTI-LEVEL?0 WELL CASING DIA:Z <br /> Q EXTRACTION d AIR HAMMER/DRIVEN CASING THICKNES5SG1( y d f TYPE OF CASING: []STEELVC []OTHER: <br /> Q VAPOR []MUD ROTARY DEPTH OF GROUT SEAL._ 3 _TREMIE TYPE TO BE USED: �UGERS �HOSE <br /> g AIR SPARGE/Ozone 1]PUSH POINT GROUT SEAL PUMPED: p Yes KNd (NOTE. MAXIMUM FREE-F `ALL DEPTH IS 3U') <br /> 0 SOIL BORING l3 HAND AUGER GROUT SPECIFICATIONS: .fes k Z Z <br /> jJ OTHER: 1]OTHER APPROX.BORING DEPTH f9 , �- LTED TAAFFIC BOX ar o STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? At C -(if YES,list specifications here): <br /> -COMMEN'TS: U 1 Oi1!% . ti, C .o <br /> io <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 /> 4r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O a es and Regulations, and all applicable California State Laws. k , <br /> Signed x 2 Title/Company - <br /> Date Ar t� <br /> Print Name. � - _� <br /> DEPARTMENT USE ONLY ` <br /> SITE MAP IN UNIT IV FILE,ADDRESS: / J�Q y f 1 ke�t 4:2 <br /> - <br /> WORK PLAN DATED: <br /> Application Accepted By G� Date Issued (��`��i3 Area I� y S3 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: A,1D# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# *on <br /> E PERMIT I SERVICE REQUEST# INVOICE <br /> 35r� Uj �'9"oa 18377 o D 33 �n9 <br /> C-57 WC -WAIVER C-57 Letter of Authn permit Encroachment do . .. .6/29/02 <br />