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nE ��v�U WELL PERMIT APPLICATION FORM SITE ' \ <br /> JUN 19 2003 ' SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 468-3449 Vi'b <br /> 'b IK G <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED J <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 /> Assessors <br /> WELL Location�9Q7 i tJesfi NW Y Z Cross Street -� City Zip 5.t 4z Parcel#05F 630•!S <br /> PROPERTY /, - <br /> Owner weS't-rec. M&C i at u.5 Address 14YAQ LO�t h'W Y ]City Zip95.t¢.t Phone# 1o9 <br /> C-57Contractorr> � Z)4-j,&vta Address,?-'5'0 HDuJ2 POCkof City&4rtf. Zi ts67 Lic#j2L5y �PhonelG20_?/3-moo <br /> Consultant/Sub Cntr 5,0C4W Ir.� f'�•. .Tu[•Addres�i 7 LaCa uEil C i�C.f'GCity�F� CLic#a — Phone#(9.75��9�T 93� <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) XDESTRUCTION (chooje,"below) <br /> OIL BORING# VOVER-BORE. DIAMETER <br /> WELL# PRESSURE GROUT 9 <br /> n•Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'MONITORING HOLLOW STEM DIA.OF BOREHOLEQ MULTIPLE CASINGS II MULTI-LEVEL WELL CASING DIA: <br /> _ " <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS 5;�,Cr• AFD TYPE OF CASING: U STEEL fPVC Q OTHER: <br /> VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL /of TREMIE TYPE TO BE USED: -(AUGERS Il HOSE <br /> AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> Q SOIL BORING HAND AUGER GROUT SPECIFICATIONS tog.e,O'II c•./ bin-fQACCI <br /> Q OTHER: n OTHER APPROX.BORING DEPTH �?D BOLTED TRAFFIC BOX or []STOVE PIPE <br /> // CONDUCTOR CASING PROPOSED- (ff YES,//li�st specifications in comment section) <br /> COMMENTS:QI�P.lpl`i�/ ( SJ G✓e(�S -(O tOfLa�l Gr�D�� .10 <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 and Regulations,and all applicable California State Laws. <br /> Signed �J��- Title/Company iT7O_4 /`T_/. I Chop <br /> Print Name /(�Ci, � LJ C��li•✓l Date D <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1606 LC I/xv/api. <br /> WORK PLAN DATED: �v <br /> Application Accepted By Date Issued (Oa,Ty Are <br /> Grout Inspection By Date Final Inspection t}y> Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DAT PERMIT/SERVICE REQUEST# INVOICE <br /> Vye a 6 � S z5 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit V Encroachment do 9/30/02 <br />