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RECE ED WELL PERMIT APPLICATION FIRM SITE <br /> SEP - 9 2005 SAN JOAQUIN COUNTY MITIGATION <br /> ENVIR0N%;1;FNT HEALTH ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> PERUi"I/SERVICES 304 E. Weber, Third Floor, Stockton, CA., 95202 <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 /> Assess <br /> WELL Locationa 5.9 g' 14,7c 4/4 s Sr. Cross Street _City L ow( Zip 3��yOParcel#�60�2 10- <br /> PROPERTY Owner Xe ,7i7/5Addressr2s,?s//jre4/YS Cityg4 Zipq;2 VOPhone#3 3it,2S <br /> C-57 DOnUaUOr .S/ Addressg.2.l W. A417' $'T Cit/4/ �09�ip9S77GLictt�oiZ33 Phone#5�16G> AYi2Y/ I' O <br /> Consultant/Sub Contractor Gft-14,?5 e E'�!✓. Address.?r?O e,&wyl woY ity ao ' //�Lic# y.��"3 Phone# 6;i;9 OR 9 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> fJEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> (SOIL BORING# I 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 22 "' MULTIPLE CASINGS?[]YES 0 NO WELL CASING DIA:V,4 <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS V44 TY/PE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR O MUD ROTARY DEPTH OF GROUT SEAL TD-SVYra CfTREMIE TYPE TO BE USED: 0 AUGERS pWyOSE <br /> 0 AIR SPARGE ",PUSH POINT GROUT SEAL PUMPED: eyes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> , OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: C I a.$S a <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH 776? 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> L (J�,,,f�/ CONDUCTOR CASING PROPOSED? A10 (if YES,list specifications here): <br /> 'COMMENTS: I &-xb 1 �^'`r" � Aj�J)' ZkS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 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 Geo /°o ose L' M✓/r0 N ^+P�"Y'4' l <br /> Print Name STe✓ ? L b M L't0 of Date 9 7 �O S <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE ADDRESS: <br /> WORK PLAN DATED: <br /> ��//— / t -7 20x1 ! S/} <br /> Application Accepted By Ajk1 ' Date Issued <br /> Grout Inspection By Date Final Inspection By —Date <br /> — <br /> Destruction Inspection By �s1 Date <br /> COMMENTS/CONDITIONS: rL V W <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> X90/ " q r cS sR# ov`f34sJ— <br /> C-57_ W(_-WAIVER— C-57 Letter of Authorization to Sign permit_Encroachment doc_ 1/25/02 <br />