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WELL PERMIT APPLICATION F'M <br /> SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 O N • 6P <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 /> F (� �t/� 1 [� C9P,4rjL Avl . Assessors <br /> WELL Locationk Z I C 00 /"TN L Avg.,Q Cross Street TNoAn-h^ QD City L pQ r Zip 95Zy s Parcel# <br /> DoKiDES Fy�,ir�/ n 2 /y// <br /> PROPERTY Owner LoKiPEO fA' rfse� Address P- 0. PGz City We0-W0tF1 Zip9S2Sd phone#tog-36 7 9-45Q <br /> C-57 Contractor Aa„♦,NceD Q(;,v£n Address 837 5/yA'v RO• CitygSi,�K f 4^Zip9 sz/sLic# bSc=Z'7dhone#=s5 -4b )-to 04 <br /> Consultant/Sub Contractor A. �i• F, Address rfl3 7 St/4v✓ RID City--570c.I-Ton Lic# ff_ 22 Phone#'t 09- ylt -/ Do If <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> KANEW WELL/BORING(CPT, E PRO YDR,QPUNCH,H D-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# f•J(e I 3 7 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: 8W%&<.6 — Grout Specifications: <br /> COMMENTS: $E o VQ (NARK /cn CIO Z <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> H MONITORING p HOLLOW STEM DIA.OF BOREHOLE Z rr MULTIPLE CASINGS?p YES p NO WELL CASING DIAN� <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_PJJA NWEDRFjASING: []STEEL 0 PVC 0 OTHER:_/V/og <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL r ja L TMIE TYPE TO BE USED: []AUGERS OSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Y s o (NOTE: MAXIMU EE-FALL DEPTH IS 30') <br /> SOIL BORING ,0`HAND AUGER GROUT SPECIFICATIONS: 1 D /yO t: <br /> Iv- <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH .55 �f 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?IvItT (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 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 tate Laws. /15 / <br /> Signed x inf' C, Title/Company //5 0% T (�/FO/ r/S% /AC r/i <br /> Print Name —T�—J,d TJ . CG It 114/— Date �5 ' 6 O 2 <br /> /D(E�PPAjRT//MENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS' �F COAL <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued �lZ Area <br /> Grout Inspection By Date Final Inspection BI ..e +a t 3Y"D Dale <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCO,YNTING ONLY: AID# rerte <br /> PE CODES FEE INFO AMOUNT REMRTED CHEECK# REC•DBY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 <br /> WC WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc 1/25/02 <br />