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0 <br /> WELL PERMIT APPLICATION FORM SITE <br /> I SAN JOAQUIN COUNTY MITIGATION <br /> F,I 6ARONMENTAL 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 Tle,Chapter 1115.3 and the f5�tandards of San Joaquin County Environmental Health Department. <br /> a�I-?o Dp CA'AA-ys�...-a-� !'sem Assessor's 95a-07 <br /> WELL Location-6 Cr'Tr acN i\nae� Cross Street P""1 Cityt"�—zip q 5316 Parcel# <br /> Dek'se Lul;si:cs Agc ( <br /> PROPERTY Owner -M, x- Address a 5(nw Ck"ismon t; .A City "� Zipq , S7?L Phone#20.1-X3S-YOI=S <br /> Tm. tY p3-_ .�— <br /> C-57 Contractor(�sep�t\t�tSfi4� ddress qSO I-1oWC R�„d Ci Norline�- Zi U5 Lic#4 bl65 phone# 935- 3i3' SB:.� <br /> Consultant/Sub Contractor URS Car;x-<oeton - Address 991tiQ Af 1,a4 C'&cc Cl� City_51w Phone# Q16-6"l9- nc <br /> Su 3Lo <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING(CP <br /> T.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> *Other: Grout Specifications: See \OC <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ^I See o.-Eke.c�ek ' crT 'Q kdn <br /> 0 MONITORING /71N FOLLOW STEM DIA.OF BOREHOLE r-r zs MULTIPLE CASINGS?D YES RflO WELL CASING DIA: V<• <br /> g4XTRACTION ! 0 AIR HAMMER/DRIVEN CASING THICKNESSSch• 40 Pic TYPE OF CASING: 0 STEEL &-PV OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Y e S TREMIE TYPE TO BE USED:'-0 AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: gyres 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0HAND AUGER GROUT SPECIFICATIONS: T`jyz =-17 P r�\a'j L �kt' 3'% he nFo n' ln 5--- <br /> f�P1THER:v ezo.+�z+cr�6&eTHER C-)­r APPROX.BORING DEPTH_ ,.40tcck- 0 BOLTED TRAFFIC BOX or OTOVE PIPE <br /> CONDUCTOR CASING PROPOSED? fJO (if YES,list specifications here): <br /> 'COMMENTS: of 2KYYl�-r'h�n �'t((t rtnc( lO n r 1 Please S<�. a-♦•4c�chp 6' til r � <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 Ordinnanceis, Rules and/R.�eegguulpations, and all applicable California State Laws. <br /> Signed ' /� tl ��L`-t' Ttle/Company .7�CTlWI'.U.9-6e'7g2 /Uf—s C4)'-21P' <br /> Print Name �zC�/A/L) k,41V DY/�E Date /' Z <br /> DEPARTMENT USE ONLY c <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> [LL/ �.Q Date Issued �! �IOZ Area OSS <br /> Grout Inspection By Date Final Inspection I _ Dale / S 2 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: - <br /> ACCOUNTING ONLY: AID# Dere <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 01 �`j " �" Od�O N 96oz SR# dv31/IL <br /> C9 %lir _te/ervGD r_F7 Letter of Authorization to Sion permit_ Encroachment doc_ 1/25/02 <br />