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Aetik 17 7_ <br />WELL PERMIT APPLICATION FORM <br />uEe 2 6 2003 <br />ENVIRONHVIEN1 ritALi ri <br />PERM1T/SERVICES <br />Cti‘av\Y- "DO e- Ply.oe1/41 az WO <br />Consultant! Sub Contractor i geAvioezt--4-izaw <br />P.0y. Fe 4 <br />GIS Coordinates: X ,Y , Township <br />SITE <br />MITIGATION <br />UNIT IV <br />30 02 <br />t3 015 37—Viz <br />,_,,,4 5- <br />c"--- C-57 Contractor AUuleSS # . City.A . <br />PP l Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. , <br />nitIT gl.: Assessor's <br />WELL Location -12-1/4- OW Bug.FA/5-r. Cross Street W- FRE, City SIOCKMjip q 5-2,9 5 Parcel# ; <br />A Lc:. tztz-E ist_As. , <br />PROPERTY Owner Gill/ DP 5T -te-k-TVAJ Address 425 N. FLDAilar) City Sibc.r._70 zi-362.9 ZPhonel# 20 -- <br />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 />' ' h b d to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br />Address 5.5-6M-0/41retOmet/i5T:t <br />tLe 14 IDE MAIU4 <br /> <br />City •se LiRtY,Apiz't?hone:145-70---.1q3,/55- LEr /3C0 <br />WORK TO BE PERFORMED: <br />1] NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />0 SOIL BORING # <br />WELL # <br />*Other: <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? fl YES B NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: fl STEEL fl PVC f OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: B AUGERS 1:1 HOSE <br />GROUT SEAL PUMPED: a Yes f No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH fl BOLTED TRAFFIC BOX or Q STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specificatipns here): I <br />TYPE OF WELL INSTALLATION TYPE <br />1 MONITORING a HOLLOW STEM <br />ilf EXTRACTION a AIR HAMMER/DRIVEN <br />#VAPOR B MUD ROTARY <br />)itgAIR SPARGE 0 PUSH POINT <br />B SOIL BORING a HAND AUGER <br />fl OTHER: 0 OTHER <br />*COMMENTS: <br />_ <br />NOTE: Lirt-SITE 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 Ord= Ru a Regulations, and all applicable California State Laws. <br />Title/Company 5-1". e'dc, 14 t S <br /> Date / <br />DEPARTMENT USE ONLY <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 I CONDITIONS: <br />iz 7ty(_( <br />Date Issued Area <br />Final Inspection By Date <br />Date <br />Date <br />1 <br />ac r <br />0, CO Li- so <br />C-57 WC -WAIVER C-57 Letter of Authorizati(On o sign permit ncroocnmenfa-o-c <br />PE CODES <br />ACCOUNTING ONLY: I AID# <br />FEE INFO AMOUNT REMITTED CHECK # REC'D,BY <br />arf <br />DATE <br />i'Z'Z fct <br />PERMITIA,F,RVICF—RE UEST # <br />SRO 9 Z, <br />INVOICE <br />1/25/0 <br />Signed x <br />Print Name <br />Grout Specifications: <br />REM- <br />Range Section <br />yIDESTRUCTIO <br />....0 <br />e be ) <br />VER-BOR —C <br />RESSURE GROUT