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ie/elsrzuUz iu: 4/ zb74bbi4dd F1FIH FLUOR PAGE 04 <br /> 0 • <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA, 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appllcatlon is hereby made to San Joaquin County for a penult to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 0-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location 1/.t9—ljooy(S, �aera�.F�o $t Cross Street 7-a Ararl< Or, Clry 4 Zip .S� 1�O�l�1Parcel# 0H--Z 961-d/ <br /> PROPERTYOwner Ne wCy1O 19'o/z -rhe . Address //�U S, SAtrnhe�n t"'a S1, City ZOOI+/�,- Zip rc'F'hone# <br /> C-57 Contractor Grer}q dr;f p,ddreyy�50t- `�cwe /Qc(, City/+'t^rr'"inf2 Zp9,�}S.3Ur#rSAOJ Phone# (96)S/J-S800 <br /> Consultant/Sub Cntr TQ Address_,!_P.S^Z Ca.,,,.rn.l�Y, City oe cc+�- Uc# Phone# IW 5-) -/-f aa <br /> GIS Coordinates:X ,Y .Township Range Section <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER'I n DESTRUCTION (choose type below) <br /> SOIL BORING# SR- 3 D OVERBORE. DIAMETER <br /> D WELL# D PRESSURE GROUT <br /> D*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n MONITORING HOLLOW STEM DIA.OF BOREHOLt�in.D MULTIPLE CASINGS 0mULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS N/A" TYPE OF CASING: [ISTEEL D PVC n OTHER: A//_,4D VAPOR D MUD ROTARY DEPTH Or GROUT SEAL 7O fit TREMIE TYPE TO BE USED: XAUGERS U HOSE <br /> UAIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: );I�Ies,/DNo (NppOTE: MAAXIMUMFREE-FALL DEPTHIS30') <br /> SOIL BORING D HAND AUGER GROUT SPECIFICATIONS NeAl- Le'+t eh I <br /> D OTHER:_n OTHER APPROX.BORING DEPTH 719 F'I; D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED /✓O (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 Ordinances, Rules'Pno Regulations,and all applicable California Statile Laws. <br /> Signed x � `lam Title/Company P+NJ F_Lr / <br /> Print Na Dale <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS= <br /> WORK PLAN DATED: <br /> Npplication Accepted By��/��<i�+-�"`-� Date Issued /,���� Areae <br /> 3rout Inspoctlon By_Fct'LL.nM-<� Date r /P9 Final Inspection By Date <br /> Destruction Inspection By Date <br /> :OMMENTS/CONDITIONS: <br /> ACCOUNTINGONLY: AID# - FAC# <br /> PE CODES FEEINFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST ft INVOICE <br /> �O( l' V7 1/ 111 / 3 03 SR# ()() 3 rP <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />