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UKIWNAL <br /> WELL„ERMIT APPLICATION FC.....M SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> 11 (209) 468-3449 CAF <br /> t I R5 NON-REFUNDABLE PERMIT EXPIRES 7 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 /> RoAP CAPi�L Avt• Assessor's <br /> WELL Location ILlte$5 N. T�toRUTon Cross Street_=Xr R..tncity 4, Lb D; zip S9 Zy5 Parcel# <br /> a'+0i#U FAe+�/y R wooPAAi06f= <br /> PROPERTY Owner Lew.:ne 'Arrw..a,},P Address �0. Bo Y l y t j City Zi�lSZS$ Phan 29 f( -7-154 <br /> l`i l ;w.' <br /> C57 Contractor G�GSCAAE pT,wa..lAddress 3632 nMEC CJIJe city�J{o Do a zip957YLtic#'7/'SfOPnone /6 /it <br /> C.. <br /> Consultant/Sub Contractor Qv Awrt e nF...:..w...- Address $S'7 .ff la w A J. City S roc CT.. Lic# bgozz7 Phone# ltZeS� 41r T/O o 1p <br /> GIS Coordinates:X 'Y 1 ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> %NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) S <br /> o SOIL BORING# 0 OVER-BORE <br /> `WELL# OS-1 IMw-14 rMw•IS I Mw•I�t MW'17,M W'I� a PRESSURE GROUT G <br /> 'Other: Grout Specifications: <br /> COMMENTS: Q <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> `,q MONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?a YES NO WELL CASING DIA: <br /> 0 EXTRACTION u AIR HAMMER/DRIVEN CASING THICKNESS R e t TYPEOF CASING: 0 STEEL VC a OTHER: <br /> 0 VAPOR u MUD ROTARY DEPTH OF GROUT SEALS o Fres.t-0GTREMIE TYPE TO BE USE ',AUGERS U HOSE X <br /> 0 AIR SPARGE - 0 PUSH POINT GROUT SEAL PUMPED: Xess p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> a SOIL BORING o E o HAND AUGER GROUT SPECIFICATIONS: &jgT LA. 0 / yJ)� <br /> OTHER: WAI¢_ Il OTHER APPROX.BORING DEPTH_ 7o FEE-)' BOLTED TRAFFIC BOX or ]]STOVEPIPE <br /> R�1W QCa — CONDUCTOR CASING PROPOSED? N♦ (if YES,list specifications here): <br /> 'COMMENTS: SEF AaRQAo WoAK PrArJ Glazer) Oel MAY ZooZ <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 OrdM'na� ^3 ncees, Rules and Regulations, and all applicable California State Laws. J <br /> Signed x / W7 /J-. M..J�� (' TlUellCompany A0 C-T FN <br /> Print Name r"M a IilLy J. \alt L(-6I\ Date 09-16' '0 2 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: (O S�aI W• e F Lo10 <br /> WORK PLAN DATED: _ /DAN �` 9 A 2 <br /> l Q p ^yl// <br /> Application Accepted By �- Date Issued 6 �lQ �r 0 Z- Area d6 " / <br /> Grout Inspection By Date Final Inspection By '�p�.�tIrP t Date RSO�j <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> , (4W 11 1732,Y 6&4 ? SR9 44312-39 <br /> C-57 ✓ WC -WAIVER— C-57 Letter of Authorization to sign permit_ Encroachment doc_ 1/25/02 <br />