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P nn FP)IW <br /> C ���UvU WELL PERMIT APPLICAlrW\�jft�� U <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 ��� J-b % 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 I g-yeo We94- 14W Y (Z Cross Street -- City O Zip 5. If 2 Parcel#OSS,6130-!S' <br /> PROPERTY �t,� <br /> Owner tVes�rrQC I 4 e'r o Gt 5 Address(4'J dM (.t),/ESS h'//W Y /Xity�_Zip 9 5.t V Phone#(Za9)369, /of/ <br /> C57 Contractor[j�q I)r•i U - aAddress?_,570 f/ou0e POO of City .8 ZirAf SS�Lic#�sr165"Phone�.?S�3/3•x�Oo <br /> Consultant/Sub Cntr 5lEl 1,,4!.. �Address57 LaCG,df to �i�r./GCiryL L.Fay�h�cLic#s Phone#�9.?5�-?94. 92ct' <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION (chooy,"below) <br /> [LSOIL BORING# )rOVER-BORE. DIAMETER <br /> WELL# p PRESSURE GROUT T <br /> a•Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING )j HOLLOW STEM DIA.OF BOREHOLE_ a MULTIPLE CASINGS 1]MULTI-LEVEL WELL CASING DIA:- " <br /> EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS 5S4. 40 TYPE OF CASING: Q STEEL fPVC []OTHER: <br /> VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL /O TREMIE TYPE TO BE USED: gAUGERS a HOSE <br /> AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> OTHER: n OTHER APPROX.BORING DEPTH .10 VBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> / / / CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS:QV -, 1 (3� (•✓evS -FO de -o,-47 <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. c� <br /> Signed x a7z: . -.- Title/Company00r�,e r_:t /J COoP .'z-.-A I/ <br /> Print Name ,-V8 r •1 b eona✓L Date D <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: OIJ w 1606 LC1(���� <br /> WORK PLAN DATED: —0 <br /> Application Accepted By Date Issued (G' Are�� <br /> Grout Inspection By Date Final Inspection By 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 DATE PERMIT*SERVICE EST# INVOICE <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit Encr9/30/02 <br />