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r l �- DD, WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> MAY 1 5 2003 SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> E��N�IIRUidi=/��NT ILALTH 304 E. Weber, THird Floor, Stockton, CA., 95202 <br /> PERM1T/3ERV!CES (209) 468-3449 <br /> i 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 F <br /> Joaquin County Development Title,Chapter 9-1115.3 and the StanCards of San Joaquin County Environmental Health Department. ' <br /> `7u!v / y/ n !> 11 C(�qt(i` Assessor's 1 <br /> WELL Location 7 `((fi/y Keft Cross Street tie. city��.zip `/S.s'16 Parcel# 2.3�'-GZo- - , <br /> p� ai;; 53.-6'rl� <br /> Z� J 7$ LD- Ci ��� Zi 75 j� Phon l ` <br /> OfL o5'�, Address. .. �' City P_--� � J ( <br /> PROPERTY Owners' l t��- <br /> IF <br /> «o p / <br /> I <br /> 'C-57 Contractor aliij I1�ZI 4L Address533 lir�ift,-}Y P S7 r7 City (a0i!✓1�- ZipU �/ �ic#`61 5�($ (}�ohe '- l7?�. <br /> (Consultant/Sub Cntr A .Lf• E Address 2,13 7­516&j ZCityS C&r'lu'# &&92/t7 Phone;6317 / J-�Oyb <br /> �GIs Coordinates:X ,Y 9 ,Township Range Section i <br /> WORK TO BE PERFORMED: <br /> 11 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') kESTRUCT�IO,`N (choose type below) ! <br /> SOIL BORING# II )(tVER-BORE <br /> WELL# 'i ' //GG,,�� fi/r�/� u'PRESSUR GROUT <br /> 'Other: 1I Grout Specificadons:lV rrrl LGlZL EA/� 10 gam: a/T.bt// <br /> COMMENTS j4B.-A[P6 D✓EGL- M�`I Qf/Lt-tlJ"CI/{MSW -7 /`�TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> i <br /> ,ll MONITORING II HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?a MULTI-LEVEL?0 WELL CASING DIA: <br /> ;�EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL I]PVC []OTHER: <br /> 0 VAPOR a MUD ROTARY - DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS o HOSE <br /> 10 AIR SPARGE/Ozone 0 PUSH POINT GROUTS EAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 1]HAND AUGER GROUT SPECIFICATIONS: - f <br /> D OTHER: a OTHER APPROX.:P.iBORING DEPTH O BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> i COMMENT$: <br /> it <br /> NOTE OFFSITE BORINGS REQUIRE ACCESS OR ENCROACH f ; s R4-(-, <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIR `NS N -. <br /> 11 Hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County 0 nce s d Regulations, and all applicable California State Laws. <br /> !!,signed Titie/Company:5'W-L„`4�r/f7 �'rt)!✓✓�I I U"r�°`��� <br /> ��'Prmt Name O+t' I. Date <br /> DEPARTMENT USE ONLY <br /> II <br /> ,SITE MAP IN UNIT IV FILE,ADDRESS: J•r <br /> WORK PLAN DATED: �v crrr ro ��x200 2 ov(�-e"e .n-1 � r % l 2Oa 2 <br /> I Application Accepted By Date it - Date Issued S O Area <br /> l Grout Inspection By. 1�(�4-w.n^r,•__ Date_ Z. c Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: r! 11 r <br /> ACCOUNTING ONLY: AID# <br /> i <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUES7# 1NVOICE <br /> iso 6o•oc/ l�sKig�s s Is o 33g Z <br /> 8/29/02 <br /> 57_ WC_-WAIVER_ C-57 Letter of;Authorization to sign permit_Encroachment doc_ <br /> C- <br />