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WELL PERMIT APPLICATION AM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> oli= D ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> OCTA 0'F3 2002 (209) 468-3449 <br /> SSUED <br /> A,ppti&"W' ereff � �a�HJoaquin Coun <br /> tyfora permit to construct EXPIRESLE PERMIT onstall�e work descnb d.FROM DATE l This application is made in compliance with San <br /> Joaquin p�l�� e �+ tie,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Departrnent.Assessoi's <br /> WELLLocation /4,50/ CghkMiik �I - Cross Street IK city�l��L[!zp �/ Parcel# Obg-(7�-&/ <br /> PROPERTY Ownerpl:Ytto l Y�Ut rpi 4�I Address. <br /> r333� Qye-r� 1 . City6QL�(&n Zip? 10 Phone# - <br /> C-57 ContractorNi��fT��JJ�L'',H2�//11Ur1<Gi Address,-21723!7 `�sf �t1�/SCity ! f ZipQr,ZLic#�54% Phone#9���3cS'"'�-z7lo <br /> Consultant/Sub Cntrl/;� Qvr, /L?I2Y'l Address ��7.�iLUAJ /moi Ci L�t.O' Lic# ZZ Phone# .�U9 -�flo7-�VO(o <br /> GIS Coordinates:X <br /> y_,Township Range Section <br /> WORK TO BE PERFORMED: <br /> CXNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) DESTRUCTION(choose type below) <br /> SOIL BORING# [I OVER-BORE <br /> HWELL# N IN L\ G 0 PRESSURE GROUT <br /> `Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'MONITORING )<HOLLOW STEM DIA.OF BOREHOLER,2S` MULTIPLE CASINGS?a MULTI-LEVEL?Q WELL CASING DIA:2N <br /> 0 EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS S-'"0 TYPE OF CASING: 0 STEEL p(PVC 0 OTHER:-- <br /> a <br /> THER: _0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL I��TREMIE TYPE TO BE USED: $,AUGERS 0 HOSE <br /> 0 AIR SPARGE/Ozone aPUSH POINT GROUT SEAL PUMPED: 0Yes 1pNo_((NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: W 1 M� CX 4U Lam} <br /> I <br /> 0 OTHER: D OTHER APPROX.BORING DEPTH 14 4-0 (00 0 BOLTED TRAFFIC BOX or 0 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 /> CountyOrdinances, Rules and Regulations, and all applicable California State Laws. (� <br /> Signed x J . Q `/J "t II � ',^ Title/Company ,cel�I�t r_ <br /> 1 I/ _ 1A LD Date IDIZ�arL <br /> Print Name �� - DEPARTMENT USE ONLY Date <br /> Q � Da f C <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 15 , 155 (, I I ' ^� V� ✓ — <br /> WORK PLAN DATED: 5.1 14 0 Z <br /> Application Accepted By Date Issued 101 L( I ov Area <br /> e <br /> Grout Inspection By - <br /> Date 101'740 ';" Final Inspection By.. Date <br /> Destruction InspectionBy Date <br /> COMMENTS I CONDITIONS. �O 1 '� <br /> ACCOUNTING ONLY: AID# <br /> PECODES FEEINFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> W $ 1- �rJ�� l� 4 3 I `-( 5 <br /> C-57_ WCWAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 8/29/02 <br /> — <br />