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iu FILE COPY <br /> r° �(sf 'I' �� C�J WELL PERMIT APPLICATION FORM SITE 4 <br /> SAN JOAQUIN COUNTY MITIGATION <br /> APR 2 6 2004 ENVIRONMENTAL HEALTH DEPARTMENT(EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 i <br /> tre i. iii: H( <br /> HEALTH (209) 468-3449 <br /> �nliniT 'FRVICES - ' <br /> FC%u: (�%!- ` NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> _ -Application is hereby 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 /> th S 1 Assessors <br /> WELL Location Cross tree <br /> IS(�lS 7f CStreet J, <br /> L S-t City LPI`kr0+7 Zip 3.30 Parcel# <br /> T— <br /> PROPERTY II ,i�p Phone# Yi<Z - 1143 <br /> Owner 1 merS •Lc. nALL n Addressl6810 S. Irl&r%An 5 33 City L-}IrrU _Zip <br /> C rX ;JUA` Address 3fo3Z Omec. Cr CRy9 010 Zip -�HLLIc# I S/ Phone#116 38-1 1 <br /> C-57 Contractor A�C4 t per 1 .., <br /> Consultant/Sub Cntr ppurr,cJ C'Rof.nV•r0 Address 937 S"w j City S-(.Y� '^ Lic# 1, O.V-I Phone# <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 (choose type below) , <br /> a SOIL BORING# Q OVER-BORE. DIAMETER <br /> ,* <br /> WELL#_ 1� 44A A <br /> ., RESSURE GROUT <br /> 0 Othe <br /> a WEILLr GROUT SPECIFICATIONS <br /> COMMENTS: I rG: ;d�sk <br /> rl <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONSCI� <br /> MONITORING a HOLLOW STEM DIA.OF BOREHOI p MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: <br /> I <br /> a EXTRACTION II AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL [IPVC I]OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes l]Na (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: p OTHER APPROX.BORING DEPTH '-a BOLTED TRAFFIC BOX or O STOVE PIPE <br /> 'f, list specifications in comment section) <br /> N PROPOSED (if YES, st p <br /> CONDUCTOR CASING - <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify t I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County es, s Re ations, and all applicable California State Laws. <br /> Signedx /� n Title/Company f Fir /'GrUGn 4r C75O <br /> Print Name Ckhdfop4er YL /1' J6/ Date y -0`I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRE S: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued �P-Grout Inspection eyDateFinal InspectioBy :M�A�re, 46 <br /> Destruction Inspection By Dale <br /> COMMENTS I CONDITIONS: Ic <br /> "ACCOUNTINGAID# FAC# <br /> AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> Encroachment doc9/30/02 <br /> _ IVER_ C-57 Letter of Authorization to sign per _ !/�OI/^s <br />