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WELL-PERMIT APPLICATION FOAM SITE <br /> SAN JOAQUIN COUNTY TION <br /> MITIGA <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT A <br /> 304 E. Weber, Third Floor, Sto *ton, 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 Ile 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 /> AssessorsWELL Location Cross Street ir 4 City k�v^ p? - 0 <br /> -07parcel#_! 70 <br /> PROPERTY Owner �! A L.&I 4 Address�,o 553 Z City 61,IA1'o 1 zip 952r��hone Z 8 � <br /> C-57 Contractor lar-- 14'-- Address_ s <br /> ,% � /7ow� /� <br /> � •.C�— / _,,., C1 G <br /> � i Zip �/SS3Lic#`�YS1d5Phone#9�S-3f3-SSS <br /> Consultant/S-6 Cn#�� rr c.!`�v�y pF d lCity—SC,�y ,, Lick Phone# 70 933- 6`T <br /> GIS Coordinates:X 'y Township Range Section <br /> WORK TO BE RERFORMED: <br /> SNE ELL ORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHERI Q DESTRUCTION (choose type below) <br /> ffWIL BORING# [JOVER-BORE. DIAMETER <br /> JXWELL# 6✓- -Z -3 -/iNl r✓-S []PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �r <br /> MONITORING -'(EOLLOW STEM DIA.OF BOREHOLES" 11 MtJLTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:2 <br /> 0 EXTRACTION '[]`AIR HAMMER/DRIVEN CASING THICKNESS Sc TYPE OF CASING: Q STEEL 0�)VC []OTHER: <br /> []VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL"-6 D e TREMIE TYPE TO BE USED: AUGERS WHOSE i <br /> []AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ,X'Yes CNo (NOTE: MAXIMU FREE-FALL DEPTH IS 30') i <br /> []SOIL BORING a HAND AUGER GROUT SPECIFICATIONS a l�1 �..�.. <br /> I <br /> [I OTHER:_0 OTHER APPROX.BORING DEPTH � OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED LID (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 /> hereby certify that I have prepared this application and that thework will be done in accordance with San Joaquin <br /> County Or , Regulations,and all applicable California State Laws. /� <br /> Signed x �"t� Title/Comps y d iJ/2- �(�^ <br /> Print Name <br /> Date Z S" 02 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: n f/� n <br /> Application Accepted ByA!A2 <br /> l . �'V �f Dae Issued �C f✓ O C 00 Z Area , <br /> Grout Inspection B a I ateO&VA Final In pection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> E <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMI ED CHECK# REC' Y ATE PERMIT/SERVICE EQUEST# INVOICE <br /> a , ala o- SR# <br /> C-57 WC -WAIVER C-57 Letter of Autho za fy <br /> o s gn permit Encroachment doc 9/30/02 <br />