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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> DEC 2 6 2003 SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 'N0i 01ML11 i HEAW h 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 /> r g-/; Assessors <br /> WELL Location 42-`FN•JAr1& N sue� i. Cross Street w' l`I�IWo CiIy Sr^-KU ,4?5203Parcel#-29W7 �—� <br /> Iai E IS L 95202 Phone#f01 ��Y-62/2 <br /> PROPERTY Owner CITY DF ; TjD kTb�Jl�(��, tAddd�ress 4P5 l•`��'.F Twin �Ciity'-5nG�1K,TDQ/�zip!6202 <br /> �,, ��AddrBs,y 0V 5 7 U "31 Ci ,ut✓v`ON ip'I�I/DLi�c#�ZJ�o P e � <br /> C-57 Contractor t(L�Gf Df" X139 <br /> g 6 �'UM)!�u-E rDEM <br /> Consultant/Sub Contractor I -+9-r-b Address S'�SKWN fGrOME/QY� City SP Lic# _ hone#���XD <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCy rJt�D�-AUGER,OTHER'*) p DESTRUCTION(choosetype below) <br /> SOIL BORING# I1�'B-"-f �++Ral�rtt-I��I` OVER <br /> W ELL# 0 PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES NO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR O MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS 0 HOSE <br /> a AIR SPARGE PUSH POINT GROUT SEAL PUMPED: flYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> VISOIL BORING 0HAND AUGER GROUT SPECIFICATIONS: <br /> a OT 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 1 i IvJp1 5 T(2 ra <br /> rr Dlf�• <br /> OTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 x <br /> TtUe/Company <br /> Date <br /> Print Name - - <br /> DEPARTMENT USE ONLY - <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: �[ <br /> Application Accepted By Date Issued Tom- � �"A ea <br /> Grout Inspection By <br /> Date Final lnspec'a Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> Vr G yCho* <br /> EACCOUNTING ONLY: AID# cera <br /> ODES FEE INFO AMOUNT REMITTED CHECK# RE D Y DATE PERMIT I SERVICE REQUEST# INVOICE <br /> '� 00 � 41 IZ SR# � <br /> C-57_ WCWAIVERC-57 Letter of Author zat' n o sign p rmit_Encroachment doc_ 1/25/0 <br /> = _ <br />