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_MID WEL- PERMIT APPLICATION FOh SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT EHD) UNIT IV <br /> 1 <br /> 304 E. Weber, Third Floor, Stockton, CA, 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE <br /> c��RM1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is pertly made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin Cqunty <br /> Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 1 f /'\,t /.}�� r i��J_j',l, �7�/ ( Assessor's <br /> WELL Location / 2/b ?W' / n Cross Streelt'Tr �P�ty> 1`C Z �W Parcel# Jj/ J� .QL( <br /> �-1 e�J�� 'P�� � city ys hone# <br /> PROPERTY Owner L s I� Ci Zp e.�/� <br /> C-57 ContractorWGST , 2, C�Address� r Z /l J t c rty,�(J Zi'SNZ-�# ' 7 Phone# <br /> Consultant/Sub Contractor F'��-1�% Address 37 SfvR--s CityyLic# Phone#c�c'3�l <br /> GIS Coordinates:X 'Y Township Range Section <br /> W RTO BE PERFORMED: <br /> ,RNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> OVER-BORE <br /> p SQ1L BORING# 0 PRESSURE GROUT <br /> Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING OLLOW STEM DIA.OF BOREHOLE i✓ I(QULTIPLE CASINGS?Q YES WELL CASING DIA: ✓lC C� <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL,2"�VC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL /Q r7-'-�T TREMIE TYPE TO BE USED: gAUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 YesNo (NOTE: AXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: LSYz <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH y f��o BOLTED TRAFFIC BOX or TOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if ES,list specifications here): <br /> COMMENTS: "'wl I�Cl"r'V G 4 L��� rZU)LYC(3 <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 /> I hereby certify that I have prepared this application and that the work will be done in ac rdance with San Joaquin County Ordinances, <br /> Rules and Regulations,and all applicable California State Laws. <br /> Signed x j <br /> /, a �,� <br /> _ Title/Company 7 <br /> Print Name vv)��qiA LIQ Date <br /> �I DEPARTMENT USE ONLY �7 <br /> SITE MAP IN UNIT IV FILE,JDRESS: I TZC c� W �.e..� <br /> WORK PLAN DATED: f <br /> Application Accepted By Date Issued Z d Area <br /> Grout Inspection By - ca-� Date 6 O Z Final Inspection By <br /> 2-- <br /> Date M <br /> t I <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 /> 1402 SR# 30gaS <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 1/25/02 <br /> FILE COPY <br />