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M � <br /> WELL PERMIT APPLICATION FORM 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 /> Assessor's <br /> WELL Location 'ppMJC--Tyot.ey- -t Cross Street Chriernan Rd.CityTrawZip 5q 376 Parcel# S5a- b70-O <br /> PROPERTY Owner lt­Ar L Addressips4nn C'61�rr an P4 City Tm� ip-CiSa2LPhone# aD9-?39.41'acl <br /> C-57 Contractor Ll�jpri ml 5 ad'Te sb�a dress 5SO H„r„e QA. CitY1kd nez Zip44L5 Lic# WS16$-Phone#cps-313-S80o <br /> Consultant hSub 6e"heetM U96 (" pt;jrnFniyn Address $$70 ,Ir 00"arCityS �ra:.�nFdic# — Phone#41br679-2060 <br /> GIS Coordinates:X Town Bt7U <br /> ,Y <br /> Township Range Section <br /> WORT E PERFORMED: <br /> BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> ®.WELL#V-r-\R — P2 a3 0 PRESSURE GROUT <br /> `Other: N O\\NJ skm A% Grout Specifications: She be�6 W <br /> COMMENTS: sec a{4a r y,",rl ,'e V laY, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING &HOLLOW STEM DIA.OF BOREHOLE (0" MULTIPLE CASINGS?BYES )}100 WELL CASING DIA: I" <br /> H EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS� A `10 TYPE OF CASING: 0 STEEL <br /> DAGb BOTHER-- <br /> B <br /> OT}{ER:0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL^ S TREMIE TYPE TO BE USED: '84tUdERS 0 HOSE <br /> 0 AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: ees p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: por-I A" '-rix p2 1t tJl 2�'e 6trA9r -w %"Z X <br /> 9,15THER:P ie2pme\0-tl OTHER APPROX.BORING DEPTH 251 Sa BOLTED TRAFFIC BOX or &STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> `COMMENTS: llns�a ll (o p yp � zvt+�1'r5 S<e- 0.11ac1 ), ork rel <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, Rules and Regulations,and all applicable California State Laws. <br /> Signed iJIWAJ\ Title/Company : rC ierk-04rxQ.aer TRS C~r• a�a}-r ala <br /> Print NamevsArafh -T6J fr`N� Dale '�'13 Ll)_� � <br /> DEPARTMENT USE ONLY Date.. <br /> MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: '1 / <br /> Application Accepted B , .� Date Issued (/ �A 7 Area 9R 7 <br /> Grout Inspection By Date ;(L_—Final Inspection By —Date— <br /> Destruction <br /> ateDestruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> cnru <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ot�( esi 89 ,00 $1,06 3SS$76 l44 ? / o SR# 6<) $S1 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to Sion permit Encroachment dor 1/25/02 <br />