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'PSC �G 'v'1fELL PERMIT APPLICATION FORM " <br /> SITE <br /> 12 SAN JOAQUIN COUNTY MITIGATION <br /> MPR a�N�NAPE ENVIRONMENTAL <br /> 041 E. Weberr, Third Floor, Stockton CA., 95202) UNIT IV <br /> ;PN�Po PaPj� (209) 468-3449 <br /> 1�0 <br /> ,, NON-REFUNDABLE PERMIT EXPIRES'I 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 Joaqu)n County Environmental Health Department. t� <br /> SfV'QL.f- Assessors <br /> r WELL Location I �'GT7e Wy Cross Street i ce-- City 4-RAS Zip X5 30 Parcel# <br /> >?(GvL2 I I <br /> PROPERT ! / ,.,7-�J" 1 I 1L r A lT _ �X <br /> Owner '4 Address ,nom-.7 I�W,tA4 City tc,4t 4c, Zip 7,733bPhone# Ci -•SS q �/-7 <br /> C-57 Contractor �' 41 –SL 0 Address el 51, f�� �6 Cit)/r'IiV MAY -zip laic#6q one# /Lf� <br /> ,./(,��,�,� C0."I it"cu}Ottn� <br /> Consultant/Sub Cntr >I 5 LV\J, Address_Ip� �1�� City �fL__-W��✓ri'`'I_ic# P—7� Phone#(����b�6-!✓OD i3 <br /> GIS Coordinates:X Y__. Township fs Range 6E Section 27 <br /> it <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING C S OGYDbUNCH,HAND AUGER,OTHER ) DESTRUCTION (ch <br /> oose type below) <br /> WSOIL BORING# OVER-BORE. DIAMETER <br /> ELL <br /> # - 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> li <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS II <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z_„_ [I MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> I <br /> 0 EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> O VAPOR [] MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> `{)tSOIL BORINGa HAND AUGER GROUT SPECIFICATIONS <br /> I 0 OTHER:_0 OTHER APPROX.BORING DEPTH 'Ky hj s 0 BOLTED TRAFFIC 80X or 0 STOVE PIPE <br /> i CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> I <br /> COMMENTS:_ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. II <br /> 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> t County Ord' ances, Rules a Re lations,and all applicable Californ' State - <br /> 1, Signed x 7t-"4-_/• G .�.V 5 Title/Company <br /> i p <br /> Print Na a �[ BD7 . f A [+-C <br /> ]I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: �J pO <br /> WORK PLAN DATED: /1 .31 D-3 (I <br /> IQ i <br /> Application Accepted B � 7 Date Issued 6 Area <br /> 1m Z <br /> Grout Inspection By Y" Date Q Final Inspection By � Date 4 .'42- Q <br /> Destruction Inspection By Date l <br /> COMMENTS/CONDITIONS: II <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35a �9 Sszq s gig sR# 37 e 0 <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/30/02 <br /> 1 I <br /> is <br />