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WELL PERMIT APPLICATION FORM, SITE!. <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA. @9 29 AM INAIT IV <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 /> Assessors <br /> WELL Location $02 W. We,beuA,re Cross Street UACO I r) City'S-t)Ckllot% Zip 85203 arcel# 145-280-OI <br /> PROPERTYtivA DQA'fo, c.�_1'J� <br /> Owner�M}yx, O�f-4no15 Address SJOq D11•LUCh`r Anfe City ✓ ej-L Df\ Zip q 5 Zt$Phone# 209- 94&-s<Zaa <br /> 00 <br /> C-57 Contractor PI;r Addressola0 N. 2r %* S+fek CityWOa�.Ine�ZipQ522 ic#8`b�13 ktte# Ste• lobfr-742zj <br /> Sul+t 255 <br /> Consultant/Sub Cntr Goxeu, Tech Address 655Ljv%wy 9SfPhone#91(o-Q2q-Ylv3f2Z. <br /> GIS Coordinates:X ,Y ,Township I W Range (7 L Section ID <br /> WORK TO BE PERFORMED: <br /> �(NEW WELL I BORING (CPT GEOPROBE,HYDRO,P,:UeNCH,HAND-AUGER,OTHER-) n DESTRUCTION (choose type below) <br /> SOIL BORING# i4S� I0&fIW -715&J C \,)Ct-f>t9C D OVER-BORE. DIAMETER <br /> WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: l 1 <br /> i5oity : 5v-(81 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING a HOLLOW STEM DIA.OF BOREHOLE 2" D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS — TYPE OF CASING: D STEEL D PVC D OTHER: <br /> D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS a HOSE <br /> D AIR SPARGE/OZONED PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes )(No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> -SOIL BORING aHAND AUGER GROUT SPECIFICATIONS f P o^n kk ky\-112 r� <br /> D OTHER: OTHER t u APPROX.BORING DEPTH 5- 10 ' n BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED '— (if YES,list specifications in comment section) <br /> COMMENTS: f. !;'t)f CAMP O S a4-%of SOr 0. or,. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROAAliMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 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�� Z Title/Company jEa.ftbn TPC'An 669t pea I <br /> Print Name 0�f0. G K' Date-912-603 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By 146 d Area <br /> Grout Inspection By Date al Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# rr REC'D BY DATE PERMIT/SERVICjREQUEST# INVOICE.00 b SR# 5 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authori do Sign permit_Encroachment doc_ 9/30/02 <br />