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WELL40ERMIT APPLICATION AM1 <br /> �� <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 7 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 Developprt�ent Title,Chapter&1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 5o.-fl bak".l 0 r<.ya -110 Assessors <br /> WELLLocation .T 4r.St i4 5 Cross Streetl�ve� CityZip 972/Q Parcel# /t <br /> IJslf <br /> PROPERTY �1; <br /> OwnerC<1;4r^; f�r�,r�.w.>t ole F1'Address°p,0.Box ZVY r• —City_5".-.- Zip S20 / Phone# 20f- 9Yd'-3 45-6C-57 Contractor h rC�q Vr;11;a 5 Address 751D We�e t?wva City,5/OG4�w Zip9ySS3 Lic#Y / Phone# QZS-313-5Yoe <br /> Consultant SubCntr�4n- r;4 vF., :rwv,.ear+�AddressZ-ZnArl. '.t,<AAn > City.so--a-- Lic##/ ,eA- Phone#707.9 zq- 69 <br /> GIS Coordinates:X Al A- ,Y AZA Township /Al Range b 1CSection <br /> WORK TO BE PERFORMED: <br /> "EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> &WELL# tAV-10, M iT/Ii ML,-12 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ''MONITORING 'HOLLOW STEM DIA.OF BOREHOLES 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2- <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sc4 yo TYPE OF CASING: O STEELkPVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL I 0 I/Y TREMIE TYPE TO BE USED:XAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes No (NOTEeeAXIMUM FREE-FALL DEPTH IS 30') <br /> U SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 3 O rII BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED N__n (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 Ordinance , les aRegulations, and all applicable California State Laws. <br /> Signedx /+L /►tM.lil� Title/CompamG"�'Wt4_r ;;&Lr AAegWP (. ,y, �/'r/� <br /> Print Name(//%ry ep,--� boo..(tagae Date O1Z�d3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: _I` W- BE'N ba' LZ P <br /> WORK PLAN DATED' <br /> Application Accepted By Date Issued Area V <br /> Grout Inspection By Date Final Inspectio Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# IN <br /> r,Dl • �3� 9-10SR# 00351 y� <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permits/(Encroachment doc_ 9/30/02 <br /> -jai Eft /oo -6s✓-az35 <br />