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WELL PERMIT APPLICATION F6( M 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 /> _ j oe po Ab0 Assessors <br /> WELL Location 237 LV. Gran I-,f�2 PACross Street E-Cry- V:1q Citya'(-acq Zip 5.9 Parcel# ZI U-02'0I7 <br /> PROPERTYOwner 04 l Pr;,dvG+S Address2olyS S,�-tll `In +001 City L01-sr-'1f �-J4 Zip` 00D Phone# SS 645-`7 06 <br /> C-57 Contractor 6^en S it V Address es µa' Ra City '% -Z Zipf ic#S 407 Phone#&?-4)�13-S�OQ <br /> P4v%c-ko <br /> Consultant/Sub Cntr-St<C0p, r,\+C> G_ '1-tLh4dress301-116-;k0'e q4 City Card rva Lic# 6S4ya2 Phone# x{16)?Ifo -OHO <br /> GIS Coordinates:X 'y Township 2 S ouT�\ Range t=a�+ Section <br /> WORK TO BE PERFORMED: <br /> PEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# GPT-2— []OVER-BORE. DIAMETER <br /> I]WELL# []PRESSURE GROUT <br /> H*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> H MONITORING H HOLLOW STEM DIA.OF BOREHOLES []MULTIPLE CASINGS []MULTi-LEVEL WELL CASING DIA: <br /> a EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: o STEEL []PVC 0 OTHER: <br /> a VAPOR []MUD ROTARY DEPTH OF GROUT SEALEAL d TREMIE TYPE TO BE USED: O AUGERS ,THOSE <br /> AIR SPARGE/OZONEPUSH POINT(GP orCPT ROUT SEAL PUMPED: $Yes HNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING []HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: H OTHER APPROX.BORING DEPTH gO []BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED QO (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 Jt;tauin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> S <br /> Signed x _Title/Company Pro* e C+ 6Ze1l tS. - �--C-0 <br /> Print Name Qr'►QYV'\ ca( _ Date -7 Q oq <br /> DEPARTMENT USE ONLY Lai <br /> SITE MAP IN UNIT IV FILE ADDRESS: 2 S O t <br /> WORK PLAN DATED: I CA 6` <br /> Application Accepted By Date Issued C <br /> Grout Inspection By_ �� e,� Date Final Inspection By Date <br /> J,�_--- -- <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3�� q.oG �� SR# 390 / Z <br /> C-57 W(_-WAIVER— C-57 Letter of Authorization to sig permit Encroachment doe 9/30/02 <br />