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„ , rr�ut n� <br /> X002 08:18 209468 33 FIFTH FLOOR <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATIQ,N <br /> SAN JOAQUIN COUNTY `, ' ^' <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 NOV 13 2002 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EMPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work desenbed. This application is msdp -� ',�"n <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health DepartmenLA <br /> Assessors <br /> WELL Location SC3CS �)r," g, Cross Street City.�1T_C>���+ Zlp �� Parcel# IGI-030-0� <br /> PROPERTY,Own <br /> Address 2-IL i l IVS`,vY �v` City SRx-tc,;c%j_ Zip 2o” Phone# 2lxi - 2 <br /> C•57 Contractor Qvw r; �wc. 'L Address fv. sT City 1�i ,�. ? Zip`f5-n(.uc#,8L ;3�{ Phone <br /> Consultant/Sub Contractor UT!'�s CALF r.' Address 12 s�.�j �- k7- City �4+ �Lict Phone# IU 3 G2� <br /> GIS Coordinates:X .Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL!.BORING(CPT,GEOPROBE,HYDP,OPUNCH,HAND-AUGER.OTHER`) DESTRUCTION(choose type below) <br /> .1e-"yi" t,C'10N 1)SOIL BORING# $OVER=BORE <br /> WELL r a PRESSURE GROUT <br /> 'Other.- \Azq l Grout Specifications: <br /> COMMENTS: CRr,�r l.J-�► � t tN 2 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONiTOPING (1 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?OYES ONO WELLCASING DIA: <br /> IT EXTFACTION n AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 8 STEEL a PVC Q OTHER: <br /> Il VAPOR g MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: .0 AUGERS p HOSE <br /> n AIR SPARGE l)PUSH POINT GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> 11 SOIL PORING r1 HAND AUGER GROUT SPECIFICATIONS: <br /> *`bTHER:,nPZf pr'3�'Q OTHER APPROX.BORING DEPTH 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 /> cA1-L THF IINtT Iv INSPF(.;TOR.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 Ordi7n-.es, les and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Name '. L�C2�,�. ��""�' Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By f� � Date Issued <br /> Grout Inspecticn By Date�f' —Final Inspection y Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDMONS: <br /> FACCOUN- ING ONLY: AID# Ger„ <br /> ODES FEEINFO AMOUNTREMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> l�C� , �� ! /r �z slims PO o <br /> C-57 WC -WAIVER C-57 Letter of Authorization to Sign permit Encroachment doc 1/25/02 <br />