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WELL PERMIT APPLICATION FOre-'M SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> UNIT Iv <br /> ENVIRONMENTAL HEALTH DEPARTMEN-1_ (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 FILE COPY <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 County Environmental Health Department, <br /> r.' /� �ry T Assessor's <br /> WELL Location 1 oq yV< 0(d!(W f la u __Cross Street Q (A Or-_City_ 1-1G C-1 Zip 9537(e Parcel# �-3j'-/53;1� <br /> PROPERTYOwner VJLICjCA-iC-1�'lrt LAN Address j/l S�y���, ' t, el City 13e# lC�E' e Zip_94 hone# /D• 52 —102`'7 <br /> C-57 Con tracto&Me,JC,G,C(qe V E/��/1� Address b27,!5 lCGGf�/r GC Cityy/Gk1Y/17 S/�Lic#- O lPhone# P-9 6- /�� <br /> Consultant/Sub CntrA duo* 66 16 a Address�37.�L1/�1.1t� Cit Cion Lic#(76022 Phone#�qkG 7-LO-0- p <br /> GIS Coordinates:X Y Township _ Range_ Section---------.-- <br /> WORK TO BE PER MED: <br /> NEW WELL ORiNG CP GEOPROBE YDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION(choose type below) <br /> G# OVER-BORE <br /> 0 WELL# _ 0 PRESSURE GROUT <br /> *Other:_ __Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE,,2 MULTIPLE CASINGS?0 MULTI-LEVEL?() WELL CASING DIA: X <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS___—k TYPE OF CASING: 0 STEEL []PVC 0 OTHER:_ <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALXTREMIE TYPE TO BE USED: []AUGERS 'HOSE <br /> 0 AIR SPARGE/Ozone)rPUSH POINT GROUT SEAL PUMPED: D Yes /0/ No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> XSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS:-- <br /> 40 H 1FG D <br /> 0 OTHER:___ n OTHER__ APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?AI& (if YES,list specifications here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE 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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> Coun Ordinances Ru es and Regulations, and all applicable California State Laws. I <br /> Signed x =/ /� ,1 _Title/Company 1ST L)A� -vim eo <br /> Print Name �N��L l�1-1 ✓� t'r Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 10 ± W - -1-3e-V'r r jj4 Tr,1fc4 , ()9 <br /> WORK PLAN DATED: 1 <br /> Application Accepted By i t r L_ ` ! ✓ Date Issued/ e' �/ U —Area /`1� <br /> bi <br /> Grout Inspection By Date Final Inspection By / ate s <br /> Destruction Inspection By Date J <br /> COMMENTS/CONDITIONS: 'Drill ] '14 2 30�_�� <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 0 0341 �0 <br /> C-57_ WC_-WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc 8/29/02 <br />