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ORIGINAL <br />WELL PERMIT APPLICATION FORg SITE <br />SAN JOAQUIN COUNTY s•2;, MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHy <br />MAR 3 1 2003 304 E. Weber, Third Floor, Stockton, CA., 9520s�y UNIT IV <br />(209) 468-3449 <br />EWRONNIEN��TTQ HE,10 i NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED `•rl <br />Applicatii�0916 4 ids aan 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 }Lg1 W S-Qdvw*ap o,.►,-CZ^MP Cross Street F-LL,tAF4t City S LDc--y-T04 Zip 1520Z. Parcel# <br />PROPERTY Owner GArVTRh-wl S Address IQ:K E. 4.4¢ I64- wort City C bcx-TD ,J Zip Phone# <br />C-57 Contractor Address Z 34,�; wt(,..jA^^ O(Z. CitySi,�v� Zip 'Zig Lic# l2 Phone# 201 -4465 -69tZ <br />Consultant/ Sub Cntr i���r ►f��.pF�(L it,JL Address Z'hi.S E. j,^'4rt4--%.& City SiocAPArr" Lic# Phone# Za11- 41(g- t3 q, <br />GIS Coordinates: X Y Township ] )-I Range 6 E Section f <br />WORK TO BE PERFORMED: <br />']] NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) [] DESTRUCTION (choose type below) <br />[] SOIL BORING # [] OVER -BORE. DIAMETER <br />t1WELL # DS2.3. L -t 5 i 30 �J 90) - 4 �30-4,.u,� -- 0L %-6o" i, [] PRESSURE GROUT <br />[] *Other �T y GROUT SPECIFICATIONS <br />COMMENTS: f k,,(L O:L-o,aE 13 o...3" A0j^-'.N�r -ryWL4-G S Pafi-tiE Pat,,t-r5 I,.��,-,4y.E� <br />of 30` , ba' . �� ka' 3f-L.o a G. rr A' -+o .% <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS „ L5-- <br />[] MONITORING 11 HOLLOW STEM DIA. OF BOREHOLEg MULTIPLE CASINGS [] MULTI-LEVEL WELL CASING DIA: I <br />[] EXTRACTION [] AIR HAMMER/DRIVEN CASING THICKNESS >c,rt 40 TYPE OF CASING: [] STEEL [] PVC [] OTHER: <br />[] VAPOR [] MUD ROTARY DEPTH OF GROUT SEAL2Z"j36-,o .r t,L-�,TREMIE TYPE TO BE USED: ]}AUGERS [] HOSE <br />B,AIR SPARGE/ OZONE [] PUSH POINT (GP or CPT) GROUT SEAL PUMPED: Yes a No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />[] SOIL BORING [] HAND AUGER GROUT SPECIFICATIONS t4tk-► <br />[] OTHER: [] OTHER APPROX. BORING DEPTH `11' 13bt,011> h�- ABOLTED TRAFFIC BOX or [] STOVE PIPE c <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) V <br />COMMENTS: <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 r <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. J <br />Signed xL::::� <br />Title/Company ST&�Ff e-,— uf��,jL <br />Print Name L -J-3 S i "%.-P .ti I Date <br />DEPARTMENT USE ONLY '0 <br />SITE MAP IN UNIT IV FILE, ADDRESS: ``0 /U <br />WORK PLAN DATED: �� - 03 <br />Application Accepted By Date IssuedETEID--Area OQ�� <br />Grout Inspection By Date Final Inspection By —Date <br />Destruction Inspection By Date <br />COMMENTS /CONDITIONS: 10,19.Z -766P <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />3.31.03 <br />SR# 0 0 3 0 b <br />C -57-k WC 1' -WAIVER_ C-57 Letter of Authorization to sign permit ✓ Encroachment doc 9/30/02 <br />Lel ��✓C�"a°t <br />