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11ritWELL ERMIT APPLICATION FO*JI Y <br /> NOV 2 4 2003 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) MITIGATION <br /> ENVIRONMENT HEALTH-; 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> PERMIT/SERVICES (209) 468_3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ON- WD <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 /> WELL Location rs� c-�'�twTf �uc� / Assessors <br /> /7 Cross Street ►"k k�!< City _57 �-��/ Zip 4�7 /Parcel# <br /> PROPERTY Owner <br /> -AA t]4d- Aet -'; Address 1'?ex 3.3.E City Zip ?5 IPhone#em's=-�T�Z-Q`/- 7 <br /> C-57 Contractor_ _ <br /> ---_Address--& �� City 1'It . Zips`�77lf'Lic# Phone# <br /> Consultant/S4 Cntr_ t2 wAddress %3UK 9t city A1.EkH L; — 7�_Phone# r-�7 2 '3 2( <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPU CH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below 8 , <br /> 0 SOIL BORING# +' •• }} <br /> 0 WELL# C/0 t f Z 31 S }d OVER-BORE. DIAMETER Y JCclrS <br /> ! / '' PRESSURE GROUT -jt aviNs <br /> a*Other ,p / , 0 i+ GROUT SPECIFICATIONS /i'f',.f G� <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL �t 1!—TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS N� <br /> Q OTHER: n OTHER APPROX.BORING DEPTH 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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or finances, R lle7�L <br /> nd Regulations,and all applicable California State LawsQ. <br /> Signed x r Title/Companyf V4 <br /> Print Name <<TZ t� Cf! ��'✓ � Date / L(/0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: o <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued �L 9 _Ar a <br /> Grout Inspection By Date IFinal Inspection : +Date <br /> Destruction Inspection By Date ViAloy <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment do� 9/30/02 <br />