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' FILE COPY <br /> ?, WELL PERMIT APPLICATION FORM SITE <br /> d,1L MITIGATION <br /> ,v u0 rtJ SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL!HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 nom, <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 ooff'San <br /> .}Joaquin County Environmental Health Department.Assessor's ,. <br /> t WELL Location 220514 <br /> C T;nJ NA.�O'wI L Cross Street /-v��/i City Zip ______Parcel# <br /> PROPERTY Owner 9RI�W/ ''\aV' Address4Q!J G Ir tKX City ZipJ=L7-�fLPhone#�fsIO�L�i}_$rj 00. 4 <br /> C-57 Contractor roft?r ( Address (oJottOWe ?i -CityNfLZip�(HISS;Lic#�a_gn7.Phone#C4b513-SSoO <br />/ Consultant/Sub Cntr �+ Vf Kr U (hoAddriess�Qlf�.011ia rp�f{4)((Qr Ci 4^4 `Lic# Phone#(�Ib)2��� <br /> GIS Coordinates:X ,Y iq Tovmshipif tj _Range l\ �O <br /> G Section Sem <br /> y� I . . j I <br /> WORK TO BE PERFORMED: {E <br /> �dNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH, AND-AUGER OTHERall 0 DESTRUCTION(choose type below) <br /> 1� OIL BORING# f Lclii C�29I OVER-BORE <br /> 'WELL# + " PRESSURE GROUT <br /> 'Other: C �I Grout Specifications:�f�Ji � S+.n.�w.e.t <br /> COMMENTS /Jct 2p� — <br /> � x <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ' <br /> a MONITORING o HOLLOW STEM Di A.OF BOREHOLE V MULTIPLE CASINGS?a MULTI-LEVEL?0 WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS— TYPE OF CASING: a STEEL p PVG,�OTHER: <br /> � <br /> a VAPOR o MUD ROTARY DEPTH OF GROUT SEAL�_TREMIE TYPE TO BE USED:, g HOSE <br /> a AIR SPARGE I Ozone p PUSH POINT GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 31 <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: <br /> U OTHER: AOTHER CTI APPROX.BORING DEPTHSO —(00 a BOLTED TRAFFIC BOX or 1}STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?moo <br /> if YES,list specifications here): t- <br /> 'COMMENTS:Q <br /> I C n . - <br /> (c ¢ C iw V. <br /> crre,�dwa�r -� les I <br /> TE: 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 Ordina Rules and Regulations, and allapplicable California State Laws. <br /> --- S a <br /> Signed x Title/Company � <br /> Print Name Date 0 ; <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted ByDate Issued 2- Area'fl aArea (/ 6 <br /> Grout Inspection By Date. Final Inspection B <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#^, - REC'D BY DATE f - PERMIT/SERVICE REQUEST# INVOICE <br /> 3501 5$Aji Vol(oo 0(�3Zro8 <br /> C-57_ WC=WAIVER_ C-57 Letterrof Authorization to sign permity/Encroachment doc_ 8/29/02 <br />