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10 • • FILE COPY <br /> WELL PERMIT APPLICATION FORM SITE <br /> APR 0 8 2003 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT EHD MITIGATION <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202) <br /> PERMIT/SERVICES UNIT IV <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> CP)'s <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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> /I .J 1 1� JV fAAGN �I Fsr A t k) ��ju Assessors <br /> WELL Locatlo Q,.t {� 6k oss Street ISS CityS Zip Parcel# <br /> �/cc E <br /> PROPERTY�.J. COJrrt; r� ..L �� ZD� �Ipp ' ...UZ�j <br /> Owner _ _ Address ��V ' """' ity IrJ'V Zip Phone# G. rlll..�� <br /> C-57Contractor f I Address cityL Zipm , .i'#O6 Phone#_[ - -7�//0W <br /> Consultant/Sub Cntr K.�p del Address efTCit Lic# "' Phone 07 L13Y <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL 1 BORING CP GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# OVER-BORE. DIAMETER <br /> 0 WELL# I � �F-RRES�SSURE GROUICATT <br /> COMMENTSthe��l.. r-.SOlf-� ar t° 25 ' � 15 J •� ti +UPES�iOl, j <br /> ! u(42cr� ItT <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING E HOLLOW STEM DIA.OF BOREHOLE_ <br /> 0 MULTIPLE CASINGS 0 MULTI-LEVEL QVELffSING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Y TYPE OF CASING STEEL 0 PVC��0/OTHER: <br /> 0 VAPOR O/IMUD ROTARY DEPTH OF GROUT SEAL MIE E TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZON2USd POINT(GP or t P�f�ROUT SEAL PUMPED: 0 s 0 No (N AXI UM FREE FALL LL EPTH IS 30') <br /> 0 SOIL BORING VVV0 HAND AUGER GROUT SPECIFICATIONS e Jy <br /> 0 OTHER:_0 OTHER APPROXI BORING DEPTH Z 0 OLTED TRAFFIC BOX 9-1-IfISTOVEPIPE <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 ce at I h e pre red this application and that the work will be done in accordance wit San Joaquin <br /> County Ord' 7: les an Regulations, and all applicable Californ"tate Laws. <br /> T►J <br /> Signed x Title/Company (Y rAT'C <br /> Print Name Date 7 <br /> DEPARTMENT USE ONLY —tom ) <br /> SITE MAP IN UNIT IV FILE,ADDRESS: h_a-xi CIU <br /> S. <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued •._ Q-p ENVIRoNM H 'y1, <br /> Grout Inspection By Date Final Inspection By '' is ,Y 3 <br /> Destruction Inspection By Date <br /> EP <br /> COMMENTS/CONDITIONS: -0- <br /> ACCOUNTING <br /> 0-ACCOUNTING ONLY: AID# I FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> tol (1 03 ¢ 8 sR# 35g3 <br /> C-57 WC—WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc 9/30/02 <br />