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FIRM <br /> FILE Y <br /> WELL•RMIT APPLICATION FO M SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 �f ' 1 <br /> (209) 468-3449 orgy• MCD <br /> NON-REFUNDABLE PERMIT EXPIRES 7 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 /> Wf5 (j Qr 6AP;f& Avi. Assessor <br /> WELL Location 44n 7W.�lE . Cross Street GA�rFeL AuL City `DD/ Zip 95zYZ Parcel# V!%-3x0-18 <br /> eu "TcAPAAY}1•pn ,./ <br /> PROPERTY Owner MC DiprDAI.OS Address 4507-Q olyC'IA+.^#0CECity 5T6CK roe-) Zip%5Zs7 Phone# -10 478-021'1 <br /> Z70 <br /> MIKE TAE77Mtbgotx> <br /> C-57 Contractor IlaWtutLD G1 fnv. Address 5'57 SgA-1 ROAD Cityr Irmm 5zip 9Sy> Lic# Phone# Z0 (4 7 100 6 <br /> Consultant/Sub Contractor '4 .G , F. Address M 7 SrfAW RAAO CityS K'111A Lic#b8o Z 2 7 Phone# t u g Y6 7 1 C C b <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/BORING(CPT. PROB HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 'SOIL BORING# P'3S 0 OVER-BORE <br /> U WELL# - 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: 5F-F- W B.C/� -fiP VQ Lvo K Gn cIo t�0 ©9 MAY Zoc T_ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS A <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Zrr MULTIPLE CASINGS?0 YES*NO WELL CASING DIA: l7� <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSlyf& TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: N�,9 <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TQlgt, Apr/*TREMIE TYPE TO BE USED: []AUGERS HOSE <br /> p AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Y s ZNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING aHAND AUGER GROUT SPECIFICATIONS: AwAmo T:fgE .777- <br /> a OTHER: 0 OTHER APPROX.BORING DEPTH $5 Rk r D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> //�� <br /> CONDUCTOR CASING PROPOSED? (if YES,/^list specificatipns here): <br /> *COMMENTS: Si:� .4+-+Ac.l�O kcFb ,S A !i 4EF- M t44 br+wdE.n R6� r N►C0 00vil f K <br /> DR jr,r0 f/•�✓T <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 /> County Ordinances,/R�ullles and <br /> Regulations, and all applicable California <br /> /State Laws. <br /> Signed x�r..aw+.4� L `. U.iN�-�.� Title/Company 7 0• fI kcc1 o1 1S% • G•� <br /> Print Name TIM'aro V cu"11AQ Date t' l '�� ' �Z <br /> DEPARTMENT USE ONLY /�,�A <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ro �� 0421' /�,^"'L y Z - <br /> WORK PLAN DATED:04' t <br /> Application Accepted By X 1 �� Date Issued � �u¢ <br /> -02' Area <br /> Grout Inspection By Date _ Final Inspection By Date <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/SERVICE REQUEST# INVOICE <br /> 35o I 1% ( Ima 31141/ <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit,_...Encroachment doc_ 1/25/02 <br />