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Aeept /0 <br />DEC 2 6 2003 <br />ENVIRONMENT HEALI 1-1 <br />PERMIT/SERVICES <br />WELL PERMIT APPLICATION FORM <br />WORK TO BE PERFORMED: <br />ri NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNC., U.:VP-AUGER, OTHER*) <br />,SOIL BORING # ILA?) — '1W-0..4 6-e— (013— <br /> <br />WELL # <br />SITE <br />MITIGATION <br />UNIT IV SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(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. Assessor's <br />WELL Location 4 2-1 • visqo oug..FA/ Cross Street 1,1/- F <br />1 <br />oq- K-C/m City 5T0(-41-7111/4Zjip 4152D '3 Parcel# <br />(..-x,142-e I 1LAS. 5-r geR2- eav 0 5 <br />PROPERTY Owner (Al Dr 5TDC-k-TDA/ Address 42.5 a)F-04:0 City s-ro zip1620 z Phone# I - -o212 <br />C-57 ContractoerR2eCA VI(POntetlitdtssY4-00 5.57f1-4 -1--- c7164144°Pliip '14-g'1)1#1,031°-3251phone# <br />13Atle- PrADN 04-DAtUteru-e 1 4 i-D Alu e mni Or i3co 415 453- <br />Consultant/Sub Contractor ---17:2-eRD1061.-147-ct4.4, Address 4-55—K4014 radmelerisr, City •6F LiciagoC9?-91hone# /6 4-40 <br />GIS Coordinates: X , Y , Township Range Section <br />r. <br />0 DESTRUCTION (choose type below) .c._ <br /> <br />0 OVER-BORE , a PRESSURE GROUT ... <br />fl <br />*Other: <br />Grout Specifications: <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: a STEEL 0 PVC ['OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br />GROUT SEAL PUMPED: B Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <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 />Title/Company <br />Date <br />TYPE OF WELL INSTALLATION TYPE <br />I] MONITORING a HOLLOW STEM <br />1:1 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />B AIR SPARGE ig:PUSH POINT <br />VSOIL BORING a HAND AUGER <br />a OT 0 OTHER <br />„..12„,., „sc., 5 -ro lae-e.e)u) <br />pov (Ai_c (5" DI 13‘.. <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 />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH <br />CONDUCTOR CASING PROPOSED? <br />fl BOLTED TRAFFIC BOX or f STOVE PIPE <br />( if YES, list specifications here): <br />S <br />Signed x <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS! CONDITIONS. <br />• <br />ACCOUNTING ONLY: AID# UYLC <br />DEPARTMENT USE ONLY <br />Date <br />Date Issued Too/L. t-fArea <br />Final Inspec *o. Date <br />- • w <br />Date <br />I * # <br />Ctita-v 4)2,1tAr- vve <br />rrerPerXdre <br />--r <br />PE CODES FEE INFO <br />C-57 WC -WAIVER C-57 Letter of Author <br />3501 <br /> <br />0.q 00 44)-0 (4- <br />RE D Y DATE PERMIT! - QUEST # INVOICE <br />4 <br />zat o sign p rmit Encroac ment .oc • 1/25/0 <br />AMOUNT REMITTED CHECK #