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>°p4UtK .O SAN JOAQUIN COUNTY SITE <br /> r i ENVIRONMENTAL HEALTH DEPARTMENT - MITIGATION <br /> N.' C <br /> { 304 East Weber Avenue, 3"Floor,Stockton,CA 95202-2708 UNIT IV <br /> (209)468-3449• Fax:(209)468-3433• Web:www.co.san-joaquin.ca.us/ehd <br /> 6• ;p <br /> 4CIFORA <br /> WELL PERMIT APPLICATION FORM <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, D, Assessors ZSZ•�-�_Q <br /> WELL Location DD nG— (.---Pcj' f'cUJ• 3LDJO Cross Street Crr++HQ1S11fAv) R9Gity T(MC� Zip I�3-1L Parcel# <br /> PROPERTY Owner�tll 'UW�. `(L�(+�LAddressZSb� `Y054'1 AJ QD City JMfiS�j ZipaI931 Phrne# Z�e1 83 4$� <br /> FA 74 tMo qq <br /> C-57ContractorTE61 1400 {te1rl Address I735-0 MOSIF-2 e"lty Ca€flovit Zip�g2Lic#-7�5b"Phone# (816)$53-9tlo <br /> Consultant ubCntrMAL"T'Ec- C, C, IS(Addresslt) GS c')[1, );MmityS+C4*lmoinc# Phone# Cllk 360—A <br /> GIS Coordinates:X .Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ' NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') a DESTRUCTION(choose type below) <br /> 0 SOIL BORING# a OVER-BORE—DIAMETER <br /> 0 WELL# a PRESSURE GROUT <br /> Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING o HOLLOW STEM DIA.OF BOREHOLE Z r MULTIPLE CASINGS?a YES�IAO WELL CASING DIA: 2+ <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS 610 — TYPE OF CASING: 0 STEEL A'PVC a OTHER: Q `Y <br /> XAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 6 r TREMIE TYPE TO BE USED: 11 n AUGERS a HOSE " 1 <br /> a AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: U Yes jjlNo (NOTE: MAXIMUM_FREE-FALL DEPTH IS 30') <br /> a SOIL BORING O HAND AUGER GROUT SPECIFICATIONS: C.ESnE NT �f '4 C0 n £ L#t Id'5' ^j <br /> 0 OTHER: OTHER PW-9 [ PVSN APPROX.BORING DEPTH I ? 11 BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? TI:A (if YES,list specificationsph�ere): <br /> 'COMMENTS: g7t2CcT PUSH L} _ 2-" cUL-A rr+e--� � Ly?'�1% <br /> ,SUYY S� .' V <br /> OTE: OF SITE 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 /> I <br /> s , PR1t�tGIpHL 1-1-4 4tNtEE1— /T1grTeC— NC- <br /> Signed x Title/Companey / <br /> Print Name S -TF V c c5• 1 Com^ y Date c,T/2- S (� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 8(VA b Stt1�' <br /> WORK PLAN DATED: <br /> Application Accepted By 4 (� �/ Date Issued `� U_/ Area <br /> Grout Inspection By ,t DatedY b / Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: /7%-0 Wl l <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE(INFO AMOUNT REMITTED CHECK If REC'''D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> G "( � SZ 6L4kdjy I SR# O b <br /> C-57_ WC---WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 WELLPERMITSITE <br /> 3m/2003 <br />