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WELL ERMIT APPLICATION AM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> 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 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 /> Assessor's <br /> WELL Location 143o S. ckteakee Lang Cross Street ke+4lawW.. city Lodi lip 752,if Parcel# <br /> PROPERTYOwner LTS Re-4-15—Address P.O. Bon 117.0 CityLodi zip 452'ilPnone#334-`ffDlk <br /> C-57Contractor F:r<cl., Env:ron�eli lgddress 39'1 5ke. (' 'I'S floce city vnlle Sri ip 95725LLic#kIL96 Phone#7"r�(-3-STO <br /> Consultant/Sub Contractor Lfr0--1 -Le.lo Address I'll'! eAot^ 5+i<e} City Escp lu Lic# Sok3 Phone#84tC-`fVys- <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> $SOIL BORING# $81, 6B2, s,5-1 %A_j DOVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: Grcut Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 1 V4 " MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:_ <br /> E EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE )&PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> .SOIL BORING aHAND AUGER GROUT SPECIFICATIONS:AeA+ cc—tft+ jedvi- FOn bdf+v, ie grour`d sue/ ct <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 55 Fi. 0 BOLTED TRAFFIC BOX or 0 STOVE PTFE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> `COMMENTS: <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, egul i nand all applicable California State Laws. <br /> Sionedz Title!Company V?r <br /> Print Name 6 Ma Cc7Ry (P, SifFl`rcL Date <1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> //���� OOtt <br /> Application Accepted By Yjk,-w�`�� Date Issued_VI(LON Area <br /> Grout Inspection 9y Date Final Inspection By Date <br /> eestructien Inscencri By Date <br /> CC7.lydENTS!CONDITIONS: A-S <br /> ACCCUNTING ONLY: AID# <br /> PE CCOES I FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57_ V.'-^--WAIVER— C-57 Letter of Authorization to sign permit_ Encroachment doc_ 1/25/02 <br />