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WELL`..)ERMIT APPLICATION F(,,,IM <br /> 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 /> j tvee - rr Assessors f70 14 <br /> WELL Location 2-2-1 EC�Ahha S ' Cross Street I\P� l�c'✓ City �K �, Zip 9%7-02- Assessors <br /> 139 - <br /> PROPERTY <br /> OwnerQQ S�a � Redd <br /> �F rk-h eyr qJ r ddress E. L,le]rvk?X 350 City �� -, Zip 2k Phone4209-734-ef-78 <br /> C-57 Contractor A Address City Zip Lic# Phone# <br /> Consultant/Sub Cntr Alf T f HSsoc"-,4c S Address_ I-Ne'PP4 Ae.)44,5city ria 1 4, , Lic# Phone# 7oe7-54Z9-2Z2/ <br /> GIs Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> Yk <br /> NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER*) []DESTRUCTION (choose type below) <br /> 'SOIL BORING# S13 1 []OVER-BORE. DIAMETER <br /> (]WELL# []PRESSURE GROUT <br /> []*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING []HOLLOW STEM DIA.OF BOREHOLE 2,1" (]MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL []PVC []OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS []HOSE <br /> (]AIR SPARGE/OZONE [] PUSH POINT(GP or CPT)GROUT SEAL PUMPED: []Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> []SOIL BORING []HAND AUGER GROUT SPECIFICATIONS <br /> []OTHER: []OTHER APPROX.BORING DEPTH []BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED—N (if YES,list specifications in comment section) <br /> COMMENTS. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR 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 Rules and Regulations, and all applicable California S/ l-ttat/e�Laws. /� <br /> Signed x- <br /> Title/Company 5+,1t CJ'o�iS� ,ATC C7TSoct—tiJe-f <br /> Print Name J ►w, G1111-1— Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDR SS: <br /> WORK PLAN DATED: 16 a a <br /> Application Accepted By Date Issued 40 A;Z: U Area < V,2 <br /> Grout Inspection By Date Final Inspection By ate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 40 dT 'fit Io a%103 1 SR# 3 <br /> C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/30/02 <br />