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JUL-29-2003 09:23 "AMBRIA 1707 93 <br /> WELL PERMIT APPLICATION FORM <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 O <br /> NON-R 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 Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department.Assessors <br /> C Y� Zip%-4 4 Parcel# 113"o'42 f 5 <br /> WELL LOCBtIon j2Le7 rl� (AubLk.-cross street e .t tCcit ,,�v1.,.,, <br /> c��[i�W► Zl 5�D Phone 4 <br /> PROPERTY Owner�.l_�' —� Addres. /� City.3[ <br /> ASO got ci Zlp 455 L;� 4 Lam?Phone 03Q-�SIpo <br /> C-57 Contractor Address n- .1 <br /> Consultant/Sub Cntr <br /> ddressZ-7p l�fklYlS Clry� )hU Lic# PhonetF.[ 3(fi <br /> GIS Coordinates:X 169 �rD�L ME� Rana Section <br /> 4zo ba rn Township 9 <br /> WORK TO BE PERFORMED: <br /> gNEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER`) []DESTRUCTION OVER-BORE. <br /> VER OR N DI(AMMEETeRe below) <br /> []SOIL BORING# a PRESSURE GROUT <br /> []WELL# GROUT SPECIR aONS <br /> IZOther <br /> COMMENTS: -2- S Q S <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING [I HOLLOW STEM DIA.OF BOREHOLE 1]MULTIPLE CASINGS []MULTI LEVEL WELL CASING DIA <br /> EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS 'TYPE OF CASING: []STEEL []PVC 0 OTHER: <br /> p VAPOR []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS p HOSE <br /> []AIR SPARGE/OZONE []PUSH POINT(QP or CPT)GROUT SEAL PUMPED: []Yee (]No (NOTE: MAXIMUM FREE-FALL DEPTH IS 90') <br /> p SOIL BORING []HAND AUGER GROUT SPECIFICATIONS <br /> BOTHER: C.-PT f1 OTHER APPROX_BORING DEPTH p BOLTED TRAFFIC BOX or a 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 that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord s, ul and Regulations, and all applicable California State Laws. <br /> /� t <br /> Signed x Title/Company LSSfi <br /> Print Name n,& ate <br /> EPARTMENT USE ONLY J <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By _ Date Issued Z'�•a3 Area Ob <br /> Grout Inspection By Date Final Inspection Date <br /> Destruction inspection By Date <br /> COMMENTS/CONDITIONS: <br /> UACCOUNTING ONLY: AID# FAC# <br /> S FEE INFO AMOUNT REMITTED CHECK# RECD ATE PERMIT/SERVICE REQUEST INVOICE <br /> C-57 /, WC /-WAIVER2 C-57 Letter of Authorization to sign permit Encroachment doc 9130/02 <br /> C <br /> TOTAL P.02 <br />