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ECr WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> JAN 2 6 2004 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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 Co my Environmental Health Department. <br /> 164 <br /> /�- qF „+ ,.�oa c J<..7- q Assessors <br /> Itt <br /> WELL Locationzy� , //�'�ross Street' t' it a c�� Ziarce <br /> PROPERTY i –/ 'S <br /> Owner– o r f/ar.r Address SZE7 t r�� >�j,.� Cly+���c•.i Zip�ilPhone# z.D g- .310 9 <br /> C-57 Contractor K"", 1,:,li,-.g, les l�g Address DC7 % 3Q City r4,4,,,EZ Zip%Z-3 Lic# 85745 Phone# 7 S <br /> Consultant/Sub Cntr S C- Address -W 00 Ave; 51°4,10 City ;2=-1 l-/, Lic# Ai A Phone# 916 FEW <br /> GIS Coordinates:X ,Y - Township Range Section <br /> WORK TO BE PERFORMED: <br /> (NEW WELL/> QRI G CPT,(�EOPROB_ HYDROPUNCH,HAND-AUGER,OTHER-) [fDESTRUCTION (choose type below) <br /> SOIL BORING# SB-j, Sd-d._sf: i Q OVER-BORE. DIAMETER <br /> 0 WELL# �.� S f 9 a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INS 1 ATION TYP CONSTRUCTION SPECIFICATIONS <br /> MONITORING a HOLLOW STEM DIA.OF BOREHOLE 3 1]MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: []STEEL Q PVC O OTHER: <br /> a VAPOR MUD ROTARY DEPTH OF GROUT SEAL L)Ij2 tT l rrn�TREMIE TYPE TO BE USED: GAUGERS Q HOSE <br /> AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> XSOIL BORING O HAND AUGER GROUT SPECIFICATIONS Veal ��- <br /> a OTHER: a OTHER APPROX.BORING DEPTH 1 f/• kn,, a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED �/A (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 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 /> Signed x (Jz�, I'�� ��1 Title/Company /= �a�.,�< i� mac,�,,�s 7 5i41[- <br /> Print Name <br /> DEPARTMENT USE ON�L�Y CVRW <br /> ,ct <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 17.55 <br /> WORK PLAN DATED: <br /> B <br /> Application Accepted y <br /> Date Issued — ��� Area �0 <br /> Grout Inspection BDate Final Inspection By z <br /> te <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> L 2qY <br /> OA0 l� S R# 3& 6,J <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ 9/30/02 <br />