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. FILE CCP' <br /> W <br /> WELL PERMIT APPLICATION FORM SITE <br /> c�g�10E SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> TE ISSUED b� i Sal, <br /> I�& <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DA <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 /> lmme4c,+dl Nor 111 of Union P.ufk Corry Ne lad Assesso <br /> Y f i' y 5376 Parcel# -—170 - 7 <br /> WELL Locationullroad Ri(,t., WA fASf df Cross Streel, eye4A St.City 1 aLT_ZiP <br /> Cenral Ne euJ Rya <br /> PROPERTY ��- Phone#1'209 <br /> OwnerWe83S-050 3 <br /> st �e lr i af.on iSf�r�Rddress City Zip <br /> C-57 ContractorG_ r"q Dry 11��_4 tTSRN Address 950140 koAf� City ar 'nLZ Zip9��3 Lick Yg�S Phone#ll�J 313-58� <br /> Consultant/Sub Cntr SAID v Address38�VyA l} AV2,5,-2bCitySacrusncn-'o Lic# Nn Phone# (41017Y-8800 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WF.LL BORING (CPT, OPROB HYDROPUNCH,HAND-AUGER,gT E * p DESTRUCTION (choose type below) <br /> SOIL B SB-A «4 S�—(o f/f� C/ t�� 0 OVER-BORE. DIAMETER <br /> a WELL# /��v 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS LY <br /> COMMENTS: SR 1 AND SB 2 ccA j6j; ,f✓t G;'fy OrTrx I'ow AND Pe.2M rrr&r> SEPAP Pr- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLE0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS !JA TYPE OF CASING: 0 STEEL G PVC a OTHER: <br /> p VAPOR UD ROTARY DEPTH OF GROUT SEALDZA Of 16o6n%rREMIE TYPE TO BE USED: 0 AUGERS p HOSE <br /> Q AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes )ENo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING a HAND AUGER GROUT SPECIFICATIONS NGRT Ce M2 f GROLtT <br /> a OTHER:_a OTHER APPROX.BORING DEPTH l5/ GQ S Q BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NA (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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, les an Regulations, an�all plicable California State Laws. 1 c <br /> Signed x Title/Company JT�F� JG!en ISI I JA /C <br /> ,1 <br /> Print Name 1/UI t�l Lt,IM S 1.111 K Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /755 Uj' �l � — r�'`'� <br /> WORK PLAN DATED: <br /> Date Issued ll— 3 Area a6 <br /> Application Accepted By ! <br /> Grout Inspection By Date Final Inspection By ,a a r' `'''` e <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/SERVICE REQUEST# INVOICE <br /> 201 � �� Q�0l2Y�o�r3 �l3-� SR# 3 '0'n� <br /> C-57_ WC _-WAIVERC-57 Letter of Authorization to sign permit E �1-moveoc <br /> % t d � 9/30/02 <br />