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FILE Y <br /> n,S L �L�l�Iu • <br /> APR 0 8 2003 WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENT HEALTH ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> PEM..11T/SERVICES 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> t (209) 468-3449 Co <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 evelopment Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> JJ (� I,' �n Assessors <br /> WELL Locatio �r 1. N QAW1 (r ross Street ^ d �C 1'v l <br /> City Zip Parcel# <br /> PROPERTY 1 / q \1 <br /> Owner We;,.,,,;ress /6���/��,(/i 'L Cih'�ip�"jib —Phone##,qZj / Ga!�a ��l//_7 L <br /> C.57Contractor ��nt C rr^^ AddressOA t/ City��OZip/✓ Lict�Jl02�Phone#�✓� 74 rr" <br /> Consultant I Sub Cntr ( ; Address City Lic#_/��Phone# � /3 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CP E P DROPUN ,HAND-AUGER,OTHER`) UCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> O WELL# 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> M EN S: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE��O MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS N TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR a//MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE SH POIN CPT)GROUT SEAL PUMPED: 0/Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Y�SOIL BORING 7777770 HAND AUGER GROUT SPECIFICATIONS SSC 4�011� —' <br /> D OTHER:_0 OTHER APPROX.BORING DEPTH 26 ' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certi tat I hav/pre red this application and that the work will be done in accordance with San Joaquin <br /> County Ord' a ces s a Regulations, and all applicable Califor State Laws. <br /> Signed x `e TillelCompany 1UrF{. <br /> Print Name Date <br /> DEPARTMENT USE ONLY o <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: APR n o ?nn3 <br /> Application Accepted By �— Date Issued l �/ pp Irea; <br /> Grout Inspection By Date Final Inspection By C=7f r <br /> L <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AIFAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SOI SR# ob <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment dor_ 9/30/02 <br /> 9P n3 I cr <br />