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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 Tille,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location lCa Chriscres�(Zoo r�y Tr�C�ross street ; 5� I�SF City lac.( Zip 537b Parceel#_1S^a-'D�a -O], <br /> r <br /> PROPERTY Owner'DLA •. 'DWt-TrLGGY Address a5Jg )('}1 smo. hRd• City_lr-r P 537(Phone#aD9-839-�� <br /> C-57 ContractorfZfr�ap•Q i TPc fddress�5d F(t,w� Q j , CityMarSLe2, Zip94553 Lic#t43516S Phone#q 313-S�a <br /> Consultant/Sub Contractor LIeS (•rrcvhsn Address Jf03 `eLIc50f' City-sgcar (p Lie# Phone#91bb9-Jooa <br /> GIS Coordinates:X .Y .Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') a DESTRUCTION(choose type below) <br /> a SOIL BORING# a OVER-BORE <br /> a WELL# PRESSURE GROUT <br /> *Other: Grout Specifications: Sec i-w\a W <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 'S�{„ -1 �.r�Lr. <br /> B,1GIONITORING BX(OLLOW STEM DIA.OF BOREHOLE Yarie-S MULTIPLE CASINGS?BYES R)6 WELL CASING DIA:Va�-S <br /> R,EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESSS - qO TYPE OF CASING: a STEEL g.FV B OTHER: <br /> n VAPOR a MUD ROTARY DEPTH OF GROUT SEALVny',,Z 5 TREMIE TYPE TO BE USED: Y AUGERS -B HOSE <br /> a AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: .awes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING aHAND AUGER GROUT SPECIFICATIONS:14ee4 wr k-' M5kbs bs,+adkc--lag l wo-}ex'qu(Ito snd/-art.-N <br /> a OTHER: a OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or a STOVE PIPE <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, R les and Reg lations,and all applicable California State Laws. <br /> Signed x /� "Z Title/Company PRCV�EC7—�AAIA 6C 4 /l/Rf CDR? <br /> Print Name k CP q e(7 VAI.1 bVK£ Date 2 2 0 2— <br /> DEPARTMENT <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: ��,Q p <br /> Application Accepted By Lek' _\ Date Issued (6/07— <br /> Grout <br /> ( DZGrout Inspection By Date Final Inspection By Date / D3 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> • cerx <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE LPERMrr/ RVICE REQUEST# INVOICE <br /> 8 `I 3/ <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 1/25/02 <br />