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WELL <br /> PERMIT APPLINOATION FOR <br /> SAN JOAQUIN COUNTY MITIGATION <br /> p 2004 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> g <br /> MAR 304 E. Weber, Third Floor, Stockton, CA., 95202(1 <br /> aNJENPERN11 SfE.RVICESFI <br /> (209) 468-3449 45-6pf) R <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 <br /> ,County Environmental Health Department Assessors <br /> µp-ICp� Q Cross Street N d- }c Cib P�'V Zip Parcel# <br /> WELL Location 4o �/ /� I'r <br /> Owner T,/,/�) 1 l S dress l) u(4A,��City 7 UI Zip Phone# <br /> Owner IM ILY.1 IAF� pp,, ��py�� ,,,,��yyryryr,�y���••�� �( p� <br /> Ci Pio" — hone#-I <br /> C-57 Contractor II.4 Address 3.� Q b <br /> Se✓S• Address � <br /> Consultant/Sub Cntr 7,16 <br /> GIS Coordinates:X <br /> y.,Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION (choose type below) <br /> p NEW WELL I BORING (CPT GEOPROB HYDROPCH,HAND-AUGER,OTHER•) 0 OVERBORE. DIAMETER <br /> 1BOIL BORING# /�/y 0 PRESSURE GROUT <br /> -0 WELL# GROUT SPECIFICATIONS�FAL' �' . <br /> O'Other S <br /> COMMENTS: <br /> T E OF WELL INSTALLATION TYPE CONSTRUCTION SPE I ATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS 0 MU`L�TI-LEVEL WELL CASING DIA: <br /> \ TYPE OF CASING: STEEL 0 PVC 0 OTHER: <br /> EXTRACTION A R HAMMER/DRIVEN CASING THICKNESS <br /> 0 VAPOR UD ROTARY DEPTH OF GROUT SEAL TTREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 9 <br /> 0 AIR SPARGE/OZONE 0 USH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS T <br /> `� OTHER APPROX.BORING DEPTH 'Z Q-BOLTED TRAFFIC BOX or D STOVE PIPE <br /> 0 <br /> OTHER:_D <br /> 1 I CONDUCTOR C SING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> �rl� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT O ENCROACH ENT PERMITS <br /> 4t$WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certi�ff tha h e prepared this application and that the work will be done in accordance with San Joaquin <br /> � <br /> County OrdjfiBnc les and Regulations, and all applicable California $t��ot S <br /> ��//LLQ Title/Company�l/--c <br /> Signedx i V Date <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> D <br /> WORK PLAN DATED: 3 �y <br /> Date Issued Are <br /> Application Accepted ByVr" Date <br /> Grout Inspection By Date Final Inspection Bever. r7 <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 I SERVICE REQUEST# INVOICE <br /> 24o1 2 51 ? sR# 003 135 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment docN 9/30/02 <br />