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t <br /> F VBG WELL PERMIT APPLICATION FORM SITE <br /> FFG SAN JOAQUIN COUNTY MITIGATION <br /> 31 jO�Q ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENZPIN� 304 E. Weber, ThirdFloor, <br /> 468 3449 ton, CA., 95202 <br /> 0 <br /> ;i Pt`NV\POO�p PPTME <br /> F NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicatiorhff h\-SN 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 9-1?15.3 and the Standards of San Joaquin County Environmental Health Department. <br /> / t (� Assessors <br /> WELL Location /���'� s• FFCLV-f(L„r IZI Crass Street , S�• City�\-f_ �.0 -_Zip '95'330 P\\arccel# mz op- <br /> PROPEF�TY \ I p �� �RJ <br /> Owner 1�Cc�,W\+AL+ _V_ <br /> Address �5�(ap 5 It-�a((t,u. lir=ity _Zip 43OPhone <br /> cbr �� pp tyWcwfvneYZip r(40?.#feoqC Phone# B <br /> C-57C n cor e — I Address � /� ✓l�i Ci <br /> i j33d Cu,mt✓-n�P <br /> Consultant I Sub Cntr�i�!`A:I-t/S C1 tJ Address Dr AC %5'50Cityl26HQr--'Lic4SS Phone# 536^•6 "C+ 6c'oy <br /> GIS Coordinates:X ,Y_-. ,Township Is Range !1� Section 2 3 <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPRO�B.E,HYI�ROPUNCI-�,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> ` OIL BORING# '(- / _Y I'L L-f'-T-3 L6'C— 0 OVER-BORE. DIAMETER <br /> 0 WELL# ' ttt 0 PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE L []MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED'. 0 Yes. []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING [] HAND AUGER GROUT SPECIFICATIONS N <br /> [] <br /> OTHER:_0 OTHER APPROX.BORING DEPTH 90 Ibis 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 Joaquin <br /> County Ordinances, Ruleand Regulations, and all applicable California State Laws.. <br /> Signed xl (: TitletCompany SA"J&S <br /> Print Name 7i,,{�/J l//}LN T. &Lrkr . 7 Date `� -%,C y <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: ®a _ <br /> WORK PLAN DATED: 1;L .3 ! T0 3 <br /> Application Accepted By "r ` Date Issued ✓/Y Q Area ( T <br /> Grout Inspection By Date—51L116 Final Inspection By Date 2 Q <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 /> sliellp y SR# 3 ?x$ ';`t, <br /> C-57_ WC!WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/30/02 <br />