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1 c 3r" t <br />WELL RMIT AFPLlCA7ION FL4M. <br />rnn a SITE <br />WIECEV E� - MITIGATION <br />D SAN JOAQUIN COUNTY <br />ENVIRONMENTAL -HEALTH DEPARTMENT (EHD) ..UNITIV t <br />SEP I O M * 304 EWeber, Third Floor, Stockton, CA., 95202 <br />ENVIRONMENT HEALTH (209) 468-3449 .�_ _ _0\1 � V r� , <br />P RItjlT/SERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED V 1 Y V V <br />Application is ere y made to San Joaquin County for a permit to construct and/or install the work described. This application is made. in compliance with San I <br />Joaquin County Development Title, Chapter 31115.3 and the Standards of San-Joaquin'County Environmental Health Department <br />WELL Location qE-� 11 5(�Qcrass saeetcny�_zP _. 3.��(oPAsseuar� <br />PROPERTYOwner �Q.tn�i - Address. U )%� H. Ci Gnn ' Zp g5aphone#Lr1)1�X N3-9Da3 <br />�o P —�Q�iC ry -- '�. <br />C-57 Contractor ��('rZ 2� ix II'v4�^driers - City___ p Lic# _7, 1(l Phone#a•) lam�� �. <br />DonsWfard/Sub Cntr +L(511�_ Addressl -? 5�L�Cityy4�,�Lcttio �OD4 Phone# 20_Vb crab <br />GIS Coordinates: X , Y - Township - Range�J- J Section r 1 <br />WORK TO BE PERFORMED: <br />�] NEW WELL/ BORING (CPT, GEOPROSE, HYDROPUNCH; HAND -AUGER, OTHER) - �DESTRUC119R (choose typebelm) <br />a SOIL BORING # / \ ( OVER -BORE <br />a. <br />WELL # - .... y,, t (� _ ,l-��SURE GROUT <br />'Other. Grout Specifications: 1 D"@X GAY ti9i%� I iV�mY 1 <br />30MMENTS %-j <br />i. <br />TYPE OF WELL INSTALLATION TYPE - CONSTRUCTION SPECIFICATIONS <br />t I <br />] MONITORING HOLLOW STEM` DIA. OF BOREHOLER•3�(/ MULTIPLE CASINGS? MULTI-LEVEL? Q WELL CASING DIA: r 'I <br />] EXTRACTION p p AIR HAMMERMRIVEN CASING THICKNESS A) A : TYPE OF CASING:, IISTEEL ll, -p PVC . U OTHER: i••` <br />I] VAPOR w p MUD ROTARY - DEPTH OF GROUT SEAL -Yrs{ TREMIE TYPE TO BE USED: KAUGERS p HOSE) { <br />Q AIR SPARGE / Ozone 0 PUSH POINT GROUT SEAL PUMPED: a Yes p No NOTE:. MAXIMUM FREE- ALL DEPTH IS 30' ` <br />!] SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: <br />.;OTHER: (9JP.( 661A.. rl OTHER APPROX. BORING DEPTH lir (] BOLTED TRAFFIC BOX or a STOVE PIPE <br />. CONDUCTOR. CASING PROPOl ( if YES, list specifications here): <br />"f-fIMMFNTR• - . <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 1 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 x - - • Title/Company . <br />Print Name - i)hV<L�. S�)C. IiY1. _ Date- q -)b- l, <br />- .. <br />'Ljr-rPM_'1IV' CP11.UJCUIYL1 <br />FEE INFO AMOUNT REMITTED - CHECK # REC-D BY <br />DATE -PERMIT I SERVICE REQUEST # <br />� <br />INVOICE r t <br />60 <br />SITE MAP IN UNIT IV FILE, ADDRESS <br />WORK PLAN DATED: <br />D131 <br />,. <br />Application Accepted By <br />Date Issu*d�l <br />Inspection Inspeon By <br />Date <br />Final <br />Destruction Inspection By <br />Date ' <br />COMMENTS I CONDITIONS: <br />- <br />i- <br />a Area V <br />_ .a Date p <br />ACCOUNTING ONLY:. AID# <br />PE CODES <br />FEE INFO AMOUNT REMITTED - CHECK # REC-D BY <br />DATE -PERMIT I SERVICE REQUEST # <br />� <br />INVOICE r t <br />60 <br />C -57-v/ WC ✓-WAIVER C-57 Lotter of, Authorization to sign permit Encroachment doc_ <br />8/29/02 <br />i <br />