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=i�f204=' 2094683. FIFTH FLOOR PAGE Lit <br /> d WELL PERMIT APPLICATION FORM <br /> SITE <br /> ,. <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA_, 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES I *F=ARF8OM DATE ISSUED <br /> Appticatlan 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 Tit*Chapter 9-1115,3 and the Standards of San Joaquin,County Environmental Health Department. <br /> E <br /> -R,,, a�l Assessor's <br /> WELL Location C//I�s p Cka 5tre 5cross Street City 5+°ck4ort Zip '?S�OQ Parcel# Q5 A-1l /ore-4 cr*i <br /> PROPERTY Owner�(1� Address`q5 N.El D6solo rj f City 5-teg-a h Zip Phone# (Z1)1)q32-86S7 <br /> C57 ;Tes#i Address 4.S0 # awe 1�d cit,"r4:, aez zip Phane*C9zs}?13-saeo <br /> SUile 340 <br /> Consultant I Sub Contractor RS Address-2 910 64 ,eWt4 O4�'S1`k GirySAcr wee r�oLio# Phang# C���1�e79-.l4oG <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> j NEW WELL!BORING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER*) 11 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# Y Z1 1 0 OVER-BORE <br /> Q WELL#kii�l� IK-t a.« I D PRESSURE GROUT <br /> 'Other WELL <br /> Specifications; <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING<,A I HOLLOW STEM DIA-OF BOREHOLE^I MULTIPLE CASINGS7"QYE5 NO WELL CASING DIA: °ZN <br /> EXTRACTION 0 AIR HAMMERIDRtVEN CASING THICKNESS 5eW -'/0 TYPE OF CAS:NG_ [I STEEL I PVC p OTHER: <br /> Q VAPOR 0 MUD ROTARY DEPTH OF'GROUT SEAL /3 TREMiE TYPE TO BE usm J AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: ❑Yes I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 31]'1 <br /> p SOIL BORING D HAND AUGER GROUT SPECIFICATIONS: Nei Ceryk?Y7 <br /> Q <br /> OTHER.—Q OTHER APPROX.BORING DEPTH 3 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> n CONDUCTOR CASING PROPDS@07 No (if YES,list specifications here): <br /> -COMMENTS: C� `� �r1 W O r 1- lar? -715'10a 41C S I <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 dome in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable Californiaa;kate Laws. <br /> Signed x 1---.— R? TiticlCompany o �aJ ( -� rte-°`^• q( �^� <br /> Phnt Name,qe-r►%o r� �L�.r7+� o l+ R4� t' d /4� 1►�7-� I��C� l c� Date <br /> DEPARTMENT USE ONLY <br /> SITEIN UNIT IV FILE ADDRESS: Z�J �' FILE 'cw <br /> SITl M , <br /> WORK PLAN DATED: k8 <br /> l t Area <br /> . <br /> Application Accepted By 1, Date Issued <br /> Grout Inspection sy Date %1 Z Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: d <br /> ACCOUNTING ONLY: JAID# <br /> Ge/`ie <br /> PE GORES FEE INFO AMOUNT REMITTED CHECK# iREC'D BY DATE PERMrrI SERVICE REQUEST 1F INVOICE <br /> qq II <br /> 35-01 <br /> -lO2 5R#t 3 b 3 <br /> C-57_ WC -WAIVER C-57 Letter of Authorization to sign p'er'mit Encroachment doc 1125/02 <br />