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WELL �,:RMIT APPLICATION FOF 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 Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> _ � Assessors <br /> R`u <br /> WELL Location /� `�t Cross Street C7 r� City S 7b C-9-rexj Zip �'i S k Parcel# <br /> PROPERTY Ownler�Gll �'�, b .'s Address S�� City Zip �,P{hone# <br /> C-57 Contractor VI k L') r w <br /> t I(r ' Address 1301E14. 16 � City f-- { ip KL41Uc#-7'ZO to /Phone# ejA 4-0-7 7 7—V1 <br /> Consultant/Sul;Cntr Vc Address 13t3 `bn 6y Z City sl�� ic# 3�E Phone# Z-61-772 —362-j <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> a SOIL BORING# o OVER-BORE. DIAMETER <br /> WELL# / 0 PRESSURE GROUT <br /> p*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS i <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE �r 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: 2 <br /> D EXTRACTION 13 AIR HAMMER/DRIVEN CASING THICKNESS 0q0 TYPE OF CASING: D STEEL}ZPVC Q OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 25" TREMIE TYPE TO BE USED: GAUGERS `,WIOSE <br /> p AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes --po (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_G OTHER APPROX.BORING DEPTH �D BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR 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 Ord" anc , Rules and Regulations,and all applicable California State Laws. <br /> L <br /> Signed x �'�`--� Title/Company .L.c..�L�-Ctif19,14y��=+�-�-�"�► <br /> Print Name C' A Date 2-126/0 j <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ano c• Aul't 5K <br /> WORK PLAN DATED: S 2 D G <br /> Application Accepted By Date Issued g A Area <br /> Grout Inspection By Date Final Inspection B ate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ;I?,GuJ 1 O-o3 SR# 33 y <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />