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�ECEj EG WELL PERMIT APPLICATION FORM SITE � <br /> SAN JOAQUIN COUNTY MITIGATION <br /> MAR ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> ,a vR �InLN1 ENj 304 E. Weber, Third <br /> 468-3449 kton, CA., 95202 UNIT IV <br /> s JO <br /> EN pEPARSM <br /> FIEPI-TN NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County mr 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 /> City <br /> ityWELL Location 00 (n//-9 IC'L" !U Cross Street S_ Zip LS 33� Assessors <br /> Parcel / 6 <br /> PROPERTY <br /> Owner DhKli"CJCrStA�IdYeIti'ei-ljb(LSr-ti Address1<1' c 5 "L— O­CINL <br /> L- OCINLnR1 eP Zpq <br /> �730Phone ;Wo 902--o -a <br /> C-57 Contractor ' V't ' t//.�/t r'e Address%5() f�'� 'ed Cit$'I"I`Me7- ZiflK!; Lic#4b'S!b p one#(e/ S� 3{3—j- <br /> Consultant/Sub Cntr - tf 3� d 11¢,'Wl tLlk ��' -t y <br /> l7/ Address � /-' Cit ""`-" Llc#�1:�/ phone# S3D-r 0146-'LCC 3 <br /> GIS Coordinates:X Y_ Township 5 Ryngy �� Section <br /> WORK TO BE PERFORMED: 7J <br /> p NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> p,.OIL BORING� 0 OVER-BORE. DIAMETER <br /> DWELL# /V1 W _ 0 PRESSURE GROUT <br /> `Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> A <br /> MONITORING `DHOLLOW STEM DIA,OF BOREHOLE 0 MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION /[]AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: STEEL ' <br /> . 0 PVC. 0 OTHER: <br /> 0 VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL �_ _S _TREMIE TYPE TO BE USED: AUGERS 0,HOSE <br /> p AIR SPARGE/OZONE. 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED. 0 Yes' �5gt'No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER. GROUT SPECIFICATIONS N <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH �S S `,BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED A(0 (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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Orc'n nces, Rules/j��d Regulations,(amend all applicable California State Laws. /\� ,/ S <br /> Signed x - '/r TitlelCompany /b -Z��' ��c' { J�Y'Y+..rris C�yI.V I�tl.y <br /> PtintName t it �C-�- <br /> Date I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: I /31 O3 <br /> GGcr <br /> Application Accepted By c-- r Date Issued 5 Y Area - <br /> Grout Inspection By�7b� Date J d F al Inspection By t Date `4 Z�- <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> kACCO1JNTIjNGNLY: AID# FAC#EE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> .2 �I � (y 00 S �F b SR# 'Z�°l`Y <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/30/02 <br /> I <br />