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WELL PERMIT APPLICATION F01W 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 /> y�az Assessors <br /> WELL <br /> WELL Location Z1t LS, W G 01A+ 1-i he � Cross Street P64-rwctiJ City Zip t�376 Parcel# ZILL-UZ-017 <br /> PROPERTY Owner J�i`Ql) ©+� PrOAUC[S Address 249LIS S. city C.ArSo:J,C.A Zip 40RIOPhone# <br /> C-57Contractor Gye51 ()rA9 Address -lam �tJw t CityJa, I&eZZip g4SSs3Lic# ygs Phone# qts 313y5�00 <br /> ��11 Rav�cl.o <br /> Consultant/Sub CntrSF­C.CZ 4--niCcnotfiionc,tAddress3dI K+Igc"e- (CC)City CordoJO, Lic# t�y�� Phone# (a�1b}8(31-01-4 DO <br /> GIS Coordinates:X Y Township_2- Sov`th Range 5 E�-aS+ Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL J BORING tr.PT r_EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> 'SOIL BORING# []OVER-BORE. DIAMETER <br /> ,WELL# tAW--8 , /AW-9 []PRESSURE GROUT <br /> []'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM-WEIIS DIA.OF BOREHOLE []MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: 2 <br /> 0 EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS Sc-V, C-h TYPE OF CASING: []STEEL )fPVC []OTHER: <br /> 0 VAPOR []MUD ROTARY DEPTH OF GROUT SEALS TREMIE TYPE TO BE USED: AUGERS []HOSE <br /> []AIR SPARGE/OZONE PUSH POINT(GP or;.;PT GROUT SEAL PUMPED: []Yes )KNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS_ <br /> []OTHER: 0 OTHER APPROX.BORING DEPTH_ _ti�J _ABOLTED TRAFFIC BOX or STOVE PIPE 1 ��• <br /> CONDUCTOR CASING PRO),OSED IV 0 (if YES,list specifications in comment section) <br /> COMMENTS; 17 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACH <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x TitlelCompany Ppg PCt Gecko i t- S�Codi �r �+ I <br /> Print Name i f e Date 0 <br /> DEPARTMENT USE ONLY �} <br /> SITE MAP IN UNIT IV FILE, DR SS: a o C <br /> WORK PLAN DATED: 3 1 O <br /> D <br /> Application Accepted By ate Issued o Area <br /> �' ��' 6 L <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTE=CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> ,Iikg5.o0 3o3b {�Q z oI SR# 3 S/ 5Z5 <br /> C-57 WC^WAIVER C-57 letter of Authorization to sign permit Encroachment doc— 9/30/02 <br />