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RECENED f • FILE COPY <br /> WELL PERMIT APPLICATION FORM SITE <br /> APR 0 8 2003 SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENT HEALTH ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> PERMIPSERVICES 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> C (209) 468-3449 6p— C b5 I r <br /> ) <br /> tT V <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r�lJ� <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 9-111 3 and the Standards of San Joaquin County Environmental Health Department. <br /> /� /� ,L, Assessors <br /> WELL LocationL(I�AT/u C1tIb Cross Street ((����\\ �k r ity LyLIJJGA',/,—�I/Z,ip Parcel# <br /> PROPERTY ERTY Address J( ' City1 2ip1./�""" Phone#�� <br /> C-57 Contractor , O l�S Address II� e. (City. A �AdfO Zip�Llict#f Phone#GLIa—J�Etl'�D�b <br /> Zo <br /> Consultant/Sub Cntr r Address LTA ✓/ City.56& VV�one# / o- <br /> GIS Coordinates:X ,Y .Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CP EOP E,HlI,HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> a SOIL BORING# Q OVER-BORE. DIAMETER <br /> p WELL# a PRESSURE GROUT <br /> a*Other / // GROUT SPE IFICATIONS <br /> COMMENTS: I 5, r3N I� GMcT} 20 6Ae .V C1 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL 0 PVC D OTHER: <br /> a VAPOR a MUD ROTARY////���� DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS a HOSE <br /> Q AIR SPARGE/OZON POINTeor CPT)GROUT SEAL PUMPED: Yes11 p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> QLFC- <br /> p SOIL BORING HAND AUGE GROUT SPECIFICATIONS�Q(C)SK(e S(i11t� �/ ?o )e ) 15`b yurfxrc .qR <br /> Q OTHER:_0 OTHER APPROX.BORING DEPTH ' <br /> BOLTED TRA FIC BOX or ()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 certify *havrepmed this application and that the work will be done in accordance with San Joaquin <br /> County Ordi ean egulations, and all applicable Californ' State Laws.Signed x Title/CompanyPrint Name Date L D <br /> DEPARTMENT <br /> �USE ONLY <br /> SITE MAP IN UNIT IV FILE, bDRESS: r✓ `�� <br /> WORK PLAN DATED: �. -� APR 0 <br /> 003 <br /> Application Accepted By < Date Issued <br /> Grout Inspection By Date Final Inspection By --9et <br /> Destruction Inspection By Date --- <br /> COMMENTS I CONDITIONS <br /> ACCOUNTING ONLY: AIof t. FAC# <br /> PE CODES FEE[ O AMOUNT REMITTED CHECK# REC'D BY GATE PERMIT I SERVICE REQUEST# INVOICE <br /> 7sto� sR# �D 3 Z.5 <br /> C-57_ WC -INATVER*� * -.E=5�/Letter of Authorization to sign permit_Encroachment doc1 9/30/02 <br /> WQ,wt�(- <br /> •� Cos J&(- <br />