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WELL PRMIT APPLICATION FOFO Y <br /> MITIGATION <br /> fNfli�liNMENF (i. i�AL1H SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> FM 3: 40304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> 03 NC 38 (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> kation is hereby made to San Joaquin County for a permit to construct and/or install the work descnoe This application is made in compliance with San <br /> uin County Development Tide,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department-Assessofs <br /> &Y57 <br /> nn e BANNER 9�• 0 D I Zip 95-7V 5 Parcel# 055 .gZ P - gl <br /> 1 Location lDy 5 /^'7 (h/ , 6AN N 2�IyvC•Cross Slheet T/{oj{r'�TAJ� RP.City <br /> )PERTY Owner (51101`1 M OP A G Address !f�3 l6 TH 5 City Si mco)ozp 95&/ y Phone#9)6 -'/43 <br /> ((�� / C Address 353 7 S N A w RO City �TocK P 9 rL��#L'VQ Phone#_z01—y0-/006 <br /> Contractor /7 In 1 <br /> F . Address `037 ig--q City S rcc.K f)-Uc# (080 2 Z 7 9`t Phone# a Y 6 7—(On cD <br /> sultant/Sub Cntr�7 �o <br /> Coordinates:X <br /> y.,Township - Range Section <br /> 2K TO BE PERFORMED: DESTRUCTION(choose type below) <br /> EW WELL/BORING( EOPROBE,HYDFjQP�t�CH,HANG-AUGER,OTHER? 0 OVER-BORE <br /> $OIL BORING# �// ""�I `-�0 PR URE GROUT <br /> n WELL# / <br /> - Grout Specifications, OI� 1 Rr0 �9F <br /> zj­ <br /> ier: <br /> VIMENTS <br /> E OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING 0 HOLLOW STEM DIA.OF BOREHCLE�' ��r�MULTIPLE CASINGS?OMULTI-LEVEL? WELL CASING DIA:N <br /> (TRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS�TYPE OF CASING: n STEEL n PVC n OTHER: N� <br /> aPOR 0 MUD ROTARY DEPTH OF GROUT SEAL S P FT, TREMIE TYPE TO BE USED: n AUGERS >jt<SE <br /> '.R SPARGE/OZOneAPUSH POINT GROUT SEAL PUMPED: 0 Yes Rio (NOTE: MAXIMUM IF EE-FALL DEPTH i 30') <br /> OIL BORING O HAND AUGER GROUT SPECIF1CATlONS: ,�/G /Rr`+D 7( �i --� <br /> OTHER APPROX BORING DEPTH 5A f T' n BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> THER: 0 if YES,list specifications here): <br /> 1-CONDUC^TOR CASING PROPOSED /�N�D(� l,' tO(fo�£g Z 0 o ,� <br /> )MMENTS: Sf-� VV D Di I� 1-k j 4 d J QU t rl—. l <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 /> ereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> )unty <br /> Ordinances, Rules and Regulations' and all applicable California-State Laws. <br /> TiTide/Company //I O 1 �C% &d/OF/S <br /> ned x <br /> / ' MoTN / .�, CV4//'9A Date_—__ 01 t. Q71 Oy <br /> nt Name DEPARTMENT USE ONLY <br /> TE MAP IN UNIT IV FILE,ADDRESS: <br /> ORK PLAN DATED: oar a3 <br /> `_ �D- <br /> ipllcadon Accepted By Date Issued w*� Date area <br /> out Inspection By Date Final Inspection By r.Y <br /> struction Inspection By Date <br /> ?MMENTS I CONDITIONS' <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35b I /- - a.o03� Z. <br /> 57 WC=WAIVER_ C-57 Letter of Authorization to sign perm Encroachment O�✓ <br /> S/29/02 <br />