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JILE COPY <br /> WELL PERMIT APPLICATION FOPU SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> 4 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> NOV 2 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMEK' HEALTH (209) 468-3449 <br /> PERMITtSERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f U V <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 9-11/15.3 and the Standards of San Joaquin <br /> anJooaquin County Environmental Health Department. <br /> AssessWELL Location -)0-7( <br /> / ( +^ 661� f'+zGwt-fly- City �1� Zip �' Pa ce#ors <br /> D�� CfJ%liGv v' r Cross Street <br /> PROPERTY Owner Address ity Zip Phone# <br /> C-57 Contractor �Y ��l�c t Address /3a?e 57' ` G, City 5 -1/7"--Zip �,5 Lic#-7 j Phone# '/6 `W7'��� <br /> Consultant/S4 Cntr ��%Lt.�G' Address ��t` O��Z' City� _3q 7 Phone# u'� 72 *_342-c <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 'DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# ,{/js- WRESSURE GROUT <br /> 0*Other ! GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:Z11 <br /> (O-EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 25 4 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS�,� � <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH Z-�p 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 certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or na ces, le and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company fLN�'�w� <br /> 4, _Y --- <br /> Print Name f ci-C'2 � � C�� ✓� Date d <br /> DEPARTMENT USE <br /> /ONLY <br /> � <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �O/ <br /> WORK PLAN DATED: //Z2-a3 <br /> Application Accepted By Date Issued �.Z'� �-� Ar a 19 <br /> Grout Inspection By Date Fi al Inspection By a <br /> Destruction Inspection ByDate <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ,3502.. WA5S 2.4 SR# <br /> C-57_ WC f-WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc� 9/30/02 <br />