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0 is URIG(NAL <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 �r <br /> (209) 468-3449 ��• �C� <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 /> }AlNNQr $q,,,r„Eq gV$ . Assessor <br /> WELLLocation (n4yo west �ALtF , Cross Street C409:1 L AUi— City 1-co; zip95zyZParcel# v56-3x-18 <br /> 'bottles °CoAPp(p•h•On <br /> PROPERTY Owner MC PAruALDS Address L150 7- �ArE Ciry STACK io.-i Zip952>7 Phone# 209 478-O0�1 <br /> n� o n+ilCE TAE rT+N R ty 5!ocK�Zip9Syi b8°=Z ' i <br /> C-57 Contractor ne�,M,ICFG 6!n Fnv. Address $�17 Sf�R.✓ OAD Ci Lic# Phone# ZL9 y( 7 00 b <br /> Consultant/Sub Contractor A Address 517 5"vJ RAA#9 City SrtxKmA Lic#6yQZ27 Phone# 109 yb> 1� b <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> gNEW WELL/BORING(CPT,(ZPROB HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> ' SOIL BORING# P-3S 0 OVER-BORE <br /> t]WELL# 0 PRESSURE GROUT <br /> 'Other: t Grout Specifications: <br /> COMMENTS 5F-F=5F-F= W6,cJ3 -f1GRA�eD OAK )014nZio tJ9 MAY 'Z0401— <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS A79 <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z" MULTIPLE CASINGS?0 YES�<NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_01& TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TolAt, xllft TREMIE TYPE TO BE USED: 0 AUGERS ,VHOSE <br /> 0 AIR SPARGE ,PUSH POINT GROUT SEAL PUMPED: 0 Yes .lrNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> iiSOIL BORING O HAND AUGER GROUT SPECIFICATIONS: fo R+ ;kW T%E <br /> 0`OTHER: 0 OTHER APPROX.BORING DEPTH ✓rS RE t 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> C�ONDUCTOR CASING PROPOSED? (if YES,list specificatigns here): <br /> 'COMMENTS: S£�— A-1'-f AC-I'�D I'/�C�SS Q 4lE�L P/1� b`r+wEEr� R6F P M cD on/a I PS <br /> 0✓1 <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,/Ruullles and Regulations, and all applicable California State Laws. �] <br /> Signed x'C--�+�" �r& � Tile/Company 7A01E'�T PQ' 51-) 7r• � / <br /> Print Name IrM OTF1Y J `wkgp— Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, C�G�ADDRESS: -(I " <br /> WORK PLAN DATED:64' S—?—O 7 <br /> Application Accepted By (\'Cf�� Date Issued L _ ea <br /> Grout Inspection By Date Final Inspection ByV g ate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCQUNTING ONLY: AID# cera <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3vO� l SRO <br /> C-572— WC—/-WAIVER— C-57 Letter of Authorization to sign permit_Encroachment dor_ 1/25/02 <br />