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WELIO'ERMIT APPLICATION 41kM 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 /> WELL Location 1-I i")'l ,n {o(n,l''i�' -�j�' . Cross Street City S'171U Z�p� ( parrxf#°rsl�� o7� <br /> PROPERTY Owner I,l lC�( �,f S')( 't`'<Address til.� �CeS� City i�i�C_�Phon a GK; - - ! <br /> C•57 Contractor iT till Address 7 ! - Q_� jj _ d1�, (,_o�hone#� <br /> V' nn dciH .mp yb -I L^ <br /> Consultant/Sub Cntrjl(Il (✓. Address_M A••„ KLA CityS '1 Lic# '}��phone# b <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERF.O ED: \, <br /> D NEW WELL/ ORI (C ,GEOPR ,HYDROPUNCH,HAND-AUGER,OTHER") p DESTRUCTION(choose type below) <br /> Q ORING# a OVER-BORE <br /> t) a WELL# PRESSURE GROUT <br /> "Other. SCi+i {I v c r Grout Spedfinfions: "/�('I iQ,U tF '� <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 11 MONITORING Q HOLLOW STEM DIA.OF 80REHOLE I•�MULTIPLE CASINGS?a MULTI-LEVEL?a WELL CASING DIA-.K& <br /> 0 EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS Ni TYPE OF CASING flSTEEL U PVC 0 OTHER: <br /> 11 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL I Om TREMIE TYPE TO BE USED: AAUGERS a HOSE <br /> 11 AIR SPARGE/Ozone-[•PUSH POINT GROUT SEAL PUMPED: p Yes Q No INOTE_ MAXIM M FREE-FALL DEPTH IS 30') <br /> ^SOIL BORING ILl H�AND AUGER GROUT SPECIFICATIONS: fit 1 lax <br /> a OTHER: f]OTHER APPROX.BORING DEPTH11OLTE&TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PD? (if YES,list specifications here): <br /> ROPOSE <br /> 'COMMENTS: �R.ar7(�c..E• n „Pn-Aar �hn�.�2-Q- �i�.r �.. Z'o �.>-C°-41 o <br /> NO—ATE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby certify that I 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 Law yEE= r+� <br /> Signed x_ c y Title/Company` y " (S)tf� //lC.�V�� fiX�"'i Pi 1x ri'• i`I AVI.C' V"W�.�• <br /> Pr nt Name (7(1Y\d ate <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I �I3 l r hvtoaJ( S f - <br /> WORK PLAN DATED: A t/b , 20o <br /> Application Accepted By `k-"-kM a in Date Issued 4Z Area <br /> Grout Inspection By - Date Final Inspection By Date <br /> Destruction Inspection By Data <br /> COMMENTS/CONDITIONS: C <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTEDCHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE - <br /> of <br /> (2,1 10 S2— 3 cf S 1 -2— <br /> C-57-- <br /> C-57_ WC_WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 8/29/02 <br />