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�?WELL�t�RMIT APPLICATION 170,. ! SITE <br /> � rt <br /> FEB 2 4 2003MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVY ,!;r�MEI`J r i-itALTH ENVIRONMENTAL HEALTH'DEPARTMENT (EHD) <br /> PtR;0)TjSERV1CHS 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> r <br /> NON-REFUNDA13LE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made in compliance with San f <br /> Joaquin County Development Tide,Chapter 9-1195.3 and the Standards of San J a'quin County Environmental Health Department. <br /> WELL Location W eSlk 56y1WC-'( S-1- Cross Street Ci �/DGI Assessors y <br /> � City I'! ZipG/S?�C . Parcel# � <br /> PROPERTY Owner<r � S Address q ZS fZ a S ;ry �B Zig _?Phone# 7�3 7 Y- <br /> Z <br /> C-57 Contractor V3eS T `AZ M-CJ4" Add res;�>—'S3 <br /> Consultant/Sub Cntr �y Address U 7 S L1::itom) City Lic# Phone#47(orog� <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> j,,NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') q DESTRUCTION(choose type belo-N) <br /> 0 SOIL BORING# [I OVER-BORE <br /> 1]WELL# `L>r-__!t5 F? Q PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> rt <br /> R�ONITORING / HOLLOW STEM DIA.OF BOREHOLE �11C MULTIPLE CASINGS?0 MULTI-LEVEL?0 WELL CASING DIA: Z i <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL a-r-VC a OTHER: - I <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL_ _ 9S�MIE TYPE TO BE USED: ErA[1GERS j)HOSE I <br /> 0 AIR SPARGE/Ozone p PUSH POINT GROUT SEAL PUMPED:1-n.es ,p Nq (N TE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> 0 SOIL BORING p HAND AUGER GROUT SPECIFICATIONS:, <br /> { a OTHER: IJ OTHER APPROX. BORING DEPTH' -2 S' r �- '(- �&LTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: t"r K) — t`e4 f✓T�'cJ�(,L / � J� LCT- __ <br /> t, t <br /> [r NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> i <br /> hereby certify that I have prepared this application and that the'work will be done in accordance with San Joaquin <br /> Zounty Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> - C, <br /> Signed x +'" _ J Tide/Company 7N C&7 <br /> print Name W! w� C.( Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: I U d/V �_J <br /> NORK PLAN DATED: O Q <br /> I \pplication Accepted By Date ✓Issued 'U Area <br /> 3rout Inspection By Date IAAr Final Inspection By Date <br /> Destruction Inspection By Date <br /> :OMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC' DATE I PERMIT/SERVICE REQUEST# INVOICE <br /> OD I ! 2 D3 <br /> '-57 WC -WAIVER C-57 Letter of Authorization t' sign pe mit Encroachment doc 8/29/02 <br />