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• <br />Signed x <br />Print Name <br />iH <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />ORIGINAL <br />11PLEIV <br />JUN 19 2003 <br />ENVIRONMENI HEALTH <br />PERMIT/SERVICES <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 />m t re 7 ST t Assessor's <br />WELL Location /0 S. t A LCorl WAN/ Cross Street tv• /Seel ti/41Y City 51-0C-K TOP) Zip cl Parcel# <br />E PROPERTY Owner D & c:•fc Address ) 77o ç,0/3. City S 7-0(,)(76,1 Zip 9 5.4/5 Phone# Z e-114'963---85?3Q <br />4A•t; io <br /> C-57 Contractor C:45C OE- DrdkAjAddress 3ipS 0.41e C C <br />P <br />oAr6v.', Zi <br />q u 2 <br />p , g—Lic# 7 610 PhOne#60 ) t•i& ii b <br />Consultant/Sub Cntr I.6.r - Address 537 SHOW City6 ra•C&Lic# 6 tv z 7 Phone#CIA c/6 7 / Or) () <br />GIS Coordinates: X , Township Range <br /> <br />Section <br /> <br />Grout Specifications: <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />0 SOIL BORING # <br />AWELL # <br />a DESTRUCTION (choose type below) <br />OVER-BORE <br />---, <br />P <br />a PlicSSURE GROUT ci) <br />oi 1/4",i9 y pc j *Other: <br />COMMENTS COMMENTS <br />INSTALLATION TYPE <br />-HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />MUD ROTARY <br />Ozone a PUSH POINT <br />fl HAND AUGER <br />11 OTHER <br />5a Af pAk.eD <br />TYPE OF WELL <br />)(MONITORING <br />['EXTRACTION <br />U VAPOR <br />a AIR SPARGE / <br />0 SOIL BORING <br />1] OTHER: <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? a MULTI-LEVEL?X WELL CASING DIA: 1 /I 0 <br />5GlikbNIE CASING THICKNESS ti 0 TYPE OF CASING: a STEEL XPVC U OTHER: <br />DEPTH OF GROUT SEAL 25 FT TREMIE TYPE TO BE USED: ,AUGERS U HOSE <br />GROUT SEAL PUMPED: t(Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: Poll r /AN.° iv, v') +- <br />APPROX. BORING DEPTH S s Fr 7&30LTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? Niv ( if YES, listmecifications here): <br />7 n+4 rs Rf ink -1:01 7/\(1,-) tkrarK 191./ joUd Z-1 i1Ay <br />On3 <br />c/) <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California Sate Laws. <br />(UL <br />Title/Company A C E C f /0,01 <br />0 - Z oo,3 <br />SITE MAP IN UNIT IV FILE, ADDRESS: I S Li t SN,c -1-1, <br /> <br />WORK PLAN DATED: <br /> <br />2 06 3 <br /> <br />3. C Liz Date <br />DEPARTMENT USE ONLY <br />COMMENTS / CONDMONS: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date Issued 06/2 Ve; Area /V 3 <br />Date Final Inspection By Date <br />Date <br />.-•/e„ .7/23 1 x - 1(//0(f <br />ACCOUNTING ONLY: <br />-• , <br />AID# _ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE RIC-111-StVx INVOICE <br />35t.1 mto IV J '6'775 CNTK_ 0,/o SR 0631372. \) <br />C-57 Letter of Authorization to si n p rmit doc 8/29/02 C-57 1,7,-WC