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WELL-rPERMIT APPLICATION F,dRM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <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 /> Z36o West C�ra n� J D^ Po m Da �-r- k C. Assessors <br /> WELL Location �-i X12 1�,Cross Street Pwrkwa�� __City � Zip Parcel# 232'I Q-P[ <br /> PROPERTY Owner Zvi C.. Address P.o• e OA -11 I City 0 Q I1ASi TX Zip I SZll Phone# <br /> C-57 Contractor G c�e5 0 r Address 9so H-0 WP- Qd City rteazip q 4SZ3Lic#y&S{6SPhone# 02-T 3 11-'s--Roo <br /> 3otl gorn. u S+e tooRu,�Gho Q!6 86 0 �- <br /> Consultant/Sub Cntr S GCcy P2 ZnitnnA+inno%1Address Ciry Gord eta Lic# 65'qq 9 Phone# C �' `#06 <br /> GIs Coordinates:X Y Township ZS Range S G E- Section I 1 <br /> WORK TO BE PERFORMED: <br /> XNEW WELL/BORING (CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") p DESTRUCTION (choose type below) <br /> SOIL BORING# , []OVER-BORE. DIAMETER <br /> V,WELL#MW-lG� X-1+ []PRESSURE GROUT <br /> []'Other GROUT SPECIFICATIONS <br /> COMMENTS:_!Sge pt ON <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'MONITORING ,HOLLOW STEM DIA.OF BOREHOLE "`� by MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA:Z ct- 9 <br /> EXTRACTION AIR.HAMMER/DRIVEN CASING THICKNESS SCK Li 0 TYPE OF CASING: []STEEL XPVC []OTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL VAc- TREMIE TYPE TO BE USED: MAUGERS []HOSE <br /> AIR SPARGE!OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: []Yes )(No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> q OTHER: []OTHER APPROX.BORING DEPTH at +aL�`td baaJKBOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED Q O (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS IkEQUIRE 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 Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company P ro l e Gf 17G010 ,`S+ ' S CO ham'AG01ti1 J' <br /> h CAr`2 Date S �I Q'� <br /> Print Name r-t Q <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 2 60 L-t adL <br /> WORK PLAN DATED: <br /> Application Accepted By " Date Issued O rea Z <br /> Grout Inspection By_� r'atm Date &172- Final Inspection By o" Date b <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3Sp( S9•od S$66Y15 SR# 3 $0�'55- <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc— 9/30/02 <br />