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N0U-04-2003 17: 18 CAMBR I R 1707 935Hi .0 /my�/y <br /> WEE-L PERMIT APPLICATION FORM SITE IU! <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) MITIGATION <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (209) 468-3449 /((/��// <br /> NON-REFUNDABLE PERMrT EXPIRES 7 YEAR FROM GATE ISSUED D A) ' ""'- <br /> Application i5 hereby made to San Joaquin County far i permit to COnetruct and/or install the Werk desclibed. This application Is made InCOmpliane0 with San <br /> Joaquin County Development Title,Chapter 31115.3 and the Standards of San Joaquin County Environmental Health Department <br /> WELL Location Z'�q`I �. 7rtMo�4 Cross Streel'F7.*[LL� :S4_ / Assessors <br /> City S72k Parcel# /51 -,ac>'o8 <br /> PROPER r^� `` <br /> Owner S / O;� r--F .4 IfSAddres1s H262 Cityl� Zip_ /$10 Phone# -93-C <br /> C-57 <br /> y o <br /> C-57 Contractor_ Address95b City�r�;g�z Zi Y5S3 LiCp tt5.(C6 Phone# RZ5-31�-5$eo <br /> Consultant/Sub Cnt1r.„c,1kr!_b1 17u;=,w," <br /> GIS Coordinates:X Y ,Townshi <br /> P Range Section <br /> WORK TO BE PERFORMED- <br /> ANEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) d DESTRUCTION (choose type below) <br /> SOIL BORING# <br /> ZWELL#_S- �^mss c_ z_gs DOVER-BORE. DIAMETER <br /> O'Other 0 PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> TYPE OF WELL I STALLAON TYP CONSTRUCTION SPECIFIC NS <br /> MONITORING 'HOLLOW STEM DIA,OF BOREHOLE_LC,_ 0 MULTIPLE CASINGS g MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSs' -L,'IC� TYPE OF CASING: U STEEL PVCOTHER: <br /> 0 VAPOR 0 <br /> 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS XHOSE <br /> Q AIR SPARGE/OZONE PUSH POINT(GP or CPnGROUT SF1�L PUMPED: ,MYe5 0 N/o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> �JrSOIL BORIN(3(GP'T) 0HAND AUGER GROUT SPECIFICATIONS Ppr-I lA-ro{ C,er.-� -C/= <br /> 0 OTHER (I OTHER APPROX.BORING DEPTH 7--9S' IOLTED TRAFFIC BOX or <br /> p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list spedfiications In comment section) <br /> COMMENTS: -E-:> 5 - ZcM Gis, $g - CPT <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 Ordirl s Rules d Regulations, and all applicable Califomia State//Laws. <br /> Signed x tJG(r TIVe/Company_ TlOt7S LVrQ�fC7/�d ���r�r <br /> Print Name rij rMA Date <br /> L�3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Data Issued f�—� Area <br /> Grout Inspection By Data __„Final Inspection By <br /> Date <br /> Destruction Inspection By Data <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE <br /> IT PERMREQUEST• INVOICE <br /> 350 1 }gg II 3 sR# pp3S9.zo <br /> C-57— WC=WAIVER C-57 Letter of Authorization to sign permit Encroachment docA/ 9/30/02 <br /> TOTAL P.02 <br />