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WELAERMIT APPLICATION FORM SITE <br /> �c[ � <br /> SAN �oAQUIN couNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> JAN 2 0 2004 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENT HEALTH (209) 468-3449 <br /> PERMIT/SER'dICES NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to constrict 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 / Assessors <br /> WELL Location cS ll Z p c�Aum.^ac Cross Street�.N a� A. City S'T�c�-�c� Zip�S __ParcelX N <br /> PROPERTYOwnerMcAro;fit- ra Address6'/ R <br /> 0Z`I NcSCc A� Cit/yS"�o� Zip�t Phone#Z �45I-S?,yy <br /> C-57 Contractor `I �-'(I-�c Address� (y <br /> 0 n, o o(. City^'ta^I�^cz.Zip $�Lic# 85 Phone#rt25'313- S8o0 <br /> Consultant/Sub Cntr (-v m br i q Address?-'40 S4ru4Ciry Sono Mi Lic#T+G'6'lL� Phone# �� 43$' .� <br /> GIS Coordinates:X <br /> �A <br /> _,y . a Township N�d Range ✓A Section N q <br /> WORK TO BE PERFORMED: - <br /> �NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ❑DESTRUCTION (choose type below) <br /> a SOIL BORING# 0 OVER-BORE. DIAMETER- <br /> WELL <br /> IAMETERWELL# tit w 'I'z- H PRESSURE GROUT <br /> p <br /> *Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS y <br /> �dONITORING -ZHOLLOW STEM DIA.OF BOREHOLE �! �a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA Z" <br /> n EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS_,' C' TYPE OF CASING: ]]STEEL gPVC []OTHER: <br /> []VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 2S TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> ❑AIR SPARGE/OZONE o PUSH POINT(GP or CPT)GROUT SEAL PUMPED: aYes []No (NO/TE: MREE-FALL DEPTH IS 30') <br /> SOIL BORING O HAND AUGER GROUT SPECIFICATIONS <br /> []OTHER: R OTHER APPROX.BORING DEPTH [I BOLTED TRAFFIC BOX or a STOVE PIPE <br /> FONDUCT�R CASING PROPOSED_ o (if YES,list specifications in comment section) <br /> COMMENTS: {�GGi<t �`'I�.C-Gl.rr,a�'T 4 •CIL <br /> NOTE: OFFSITE BO INGS 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 Ordinances Rules d Regulations, and all applicable California State Laws. �» <br /> Signed _Title/Company�.XJE'M6r'I2Z <br /> Print Name Date /�r/o y <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 6 13 ( Pa cs �n e /k�a cts l-05 c C <br /> WORK PLAN DATED: 31b 3 <br /> Application Accepted By Date Issued IZ O Area Z( <br /> Grout Inspection By (,L'S'L4 nr Date 2 f r O` Final Inspection By US-, 'ter Date Z r O`�' <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: qAM <br /> FAC# <br /> PE CODES FEE INFOtNTRITTEDBC-.HCK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 0� �� !� 2 i z---L bl 11 S R# 3.� T3 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />