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• 0 ORIGINAL <br /> WELL PERMIT APPLICATION FORM 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 <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 /> Rohe CAPiJkt. Ave. Assessor's <br /> WELLLocation IybSq N. TftoAUTcn CrossStreet-iiuAdT R.ADCity & Lo01 Zip .$9 Zy5 Parcel# <br /> t3,'m; tS F`ArTA, WooP"A106E <br /> PROPERTY Owner L(welreA iArTw.ali,D AddressPa, QcX IY�/ City Zip9$75jj Phone(2n S6 435a <br /> Drill;ng AAN,NO 7)75/0 <br /> C-57 Contractor CASCADE I Address302LC1NtEC Cirdt CityCOAOovA ZIP9S7Y?-Uc# Phone 16 -6 //6 <br /> Consultant/Sub Contractor fldvtimteA FG..,eol.ew...-,)AJdress 'bS-7 54Aw A� . City SfoCCPon Lic# 68atZ7Phone#-2z 41, 7/Oc11r <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 3(NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> " iVELL# OS-1 ItAw-IM.Mw•L$� MW•HMV•/-17,Mw-t� aPRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I/ <br /> MONITORING 1KHOLLOW STEM DIA.OF BOREHOLE R n MULTIPLE CASINGS?0 YES ANO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS C v e TYPEeOF CASING: 0 STEEL VC 0 OTHER: <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALS o FYf z b5 TREMIE TYPE TO BE USE AUGERS p HOSE <br /> 0 AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: Wes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING� E 0 HAND AUGER GROUT SPECIFICATIONS: NA TLAwO / _X-f� <br /> OTHER: S VASO OTHER APPROX.BORING DEPTH 7(> Ft-F-4- IkOLTEDTRAFFICBOX or 0 STOVE PIPE <br /> R W©,cts — CONDUCTOR CASING PROPOSED? N• (if YES,list specifications here): <br /> 'COMMENTS: SEF AeleRoyto W oAK PPIar,/ 4 Tfin CA MAY ZOo7- <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 Ord'nances, Rules and Regulations, and all applicable Californian State Laws. l <br /> Signedx 6 / I- w.�J'� —) r Title//Company /RO�CT GjN o <br /> Print Name rMD%7'l;21 L'(-#$& Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 7d dw • �X LAP <br /> WORK PLAN DATED: S 9 d 2- <br /> . -i <br /> Application Accepted By C` Lw/C�_ Date Issued L �l6 O L Area <br /> a <br /> Grout Inspection By Date._ Final Inspection By 6 & a1 Date �O j <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# cera <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> a5o1 I�Aw l73z� Cmc ? <br /> SRU 0U.2 39 <br /> C-57✓ WC -WAIVER-- C-57 Letter of Authorization to sign permit_Encroachment doc_ 1/25/02 <br />