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DIY � pf <br /> i��I�';i'�S �� ` <br /> WELL JRMIT APPLICATION EC ,4 <br /> ''"" �� SITE <br /> OCT - 1 2003 SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> V ON ENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 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. <br /> � A/Phi Z � � n Assess <br /> or's <br /> WELL Locaion W CS! � Cross Street UvFST L ;JN_City $`T6CKTParcel# <br /> PROPERTYOwner URNnnt Pal en� Address fl• ya � <br /> City STOc.�i3n Zip j5 Phone#(Zc q(p6"�c1/a <br /> oc�« M, A2z Q W� y ANu�e Gla �/ <br /> C�7 Contractor Mt G�¢lI �!tlI►r9 Address Ncl�e Cs G City Cfl,�1p�� Zip956 Te Lic# Phone# 9l 63�3✓- 5 <br /> A <br /> 15 To <br /> Consultant/Sub Cntr A - G . Address 63,7 514A t,,j AD CityS irmeron Lic# p Oa?a 7 Phone4Z�9) 16 7 i 0 n <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ` AEW WELL ORI G CPT, GEOPROBE,HYDROPUNCH;HAND-AUGER THER*) L,DESTRUCTION(choose type below) <br /> \` SOIL BORING# iQ - P-/0P-11 r P--12- 0 OVER-BORE <br /> 1]WELL# 17 PRESSURE GROUT <br /> *Other. Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS A <br /> 1]MONITORING �10LLOW STEM DIA.OF BOREHOLE �� MULTIPLE CASINGS?[]MULTI-LEVEL?0 WELL CASING DIA:q <br /> p EXTRACTION 11 AIR HAMMER/DRIVEN CASING THICKNESS N/A- TYPE OF CASING: 1]STEEL a PVC a OTHER: N/At <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEALr4AI DEP l 14 TREMIE TYPE TO BE USED:�UGERS 0 HOSE <br /> 1]AIR SPARGE/Ozone 0 PUSH POINT GROUT SEAL PUMPED: es Vo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30'j <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: n( �'- -Tys <br /> Q OTHER: ❑OTHER APPROX.BORING DEPTH 513 FPy-- T 11 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> p CONDUCTOR CASING PROPOSED?'! A (if YES,list specifications here): <br /> *COMMENTS:_SEL W ORK f 4N , 011 RW 03 vj I y Z 0cL3 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi ances, Rules d Re ulations, and all applicable California State Laws. <br /> Signed x Title/Company )4660- 6160/CD o <br /> Print Name CV ClAA, Date Obi <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 82, 30 L a n <br /> WORK PLAN DATED:- 3 2003 <br /> Application Accepted By p Date Issued 101- 2 .-.03 Area 145-q <br /> Grout Inspection By Y6dwlaLDate /t) Final Inspection Byhd4yv'�, Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: j -- <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT J SERVICE REQUEST# INVOICE <br /> 350199,00 ""g9, 0dSf1 0035-497 <br /> C-57 WC -WAIVER - C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02 <br />