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WELL PERMIT APPLICATION FORD SITE <br /> S MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ` ENVIRONMENTAL HEALTH DEPARTMENT(EHD) <br /> 17 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> S; `L (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 Joaquin County <br /> Development Title,Chapter 9-1115.3 and the Standards of San Joaquin Coui?ly Environmental Health Department <br /> L /� ,,/ Assessor's <br /> WELL Location �' fip ppW�f w� Cross Streetp �Cliy�t -_ Jf?Zip�15G,1U�/f�--Parcel# <br /> PROPERTY Owner Y� Nde+�U(e s Address �1 t h�! ity Si7 vr.(�G TSP °?rv�Phone# 2 d 3 <br /> C-57 Contractor Address !63:7 C) _W City ZipZj J7Phone# �?j l�/l%�, <br /> :onsultantI Sub Contractor_ C7� Address 937 (;6aj6 _ City­5j2_4!�_l.ic#6 1l� �Phone# <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> I EW WELL/BORING(CPT,GEOPROBE,HYDROPHAND-AUGER,OTHER-) Q DESTRUCTIJN(choose type below) <br /> { <br /> OIL BORING# U H, Q OVER-BORE <br /> [I WELL# [1 PRESSURE GROUT <br /> *OtherGrout Speuficailons: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?[I YES O WELL CASING DIA <br /> Q EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: o STEEL a PVC 0 OTHER: <br /> [)VAPOR {]MUD ROTARY DEPTH OF GROUT SEAL__'a,"�� TREMIE TYPE TO BE USED: 0 AUGERS o HOSE <br /> AIR SPARGEUSH POINT GROUT SEAL PUMPED: (]Yes o-(_N1OTE:&1AXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: , [ Gt7 x <br /> [j OTHER: fl OTHER APPROX.BORING DEPTH 1!j'4- 36' a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSEO?�if YES,list specifications here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE 60RINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certlfj that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> Rules and R ulations, nd al applicable California State Laws. II <br /> Signed z Title/Company T <br /> Print Name 1 Ct I 1'�PIOV7 Date / <br /> DEPARTMENT USE ONLY <br /> PAYMEN� <br /> SITE MAP IN UNIT IV FILE,ADDREJS: ECEI�/EU <br /> WORK PLAN DATED: <br /> C, 222Q�2 pY 2220fl2 <br /> Application Accepted By Date Issued Grout Inspection Inspection By a Final Inspection By Date JOA{lU1N GO�ICtS <br /> Destruction Inspection By2. <br /> V/LDate 8L1C HEALTH 5EkNI I ti 01VISIr,f <br /> ENVt <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAG# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#t RECD BY DA PERMIT f SERVICE=REQUEST# INVOICE <br /> 2 Q0 g �l ooZ SR# Z <br /> C-57_ WC -WAIVED_._- C-57 Letter of Authorization to sig a mit_Encroachment doc�— 1/25/02 <br />