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0 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 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 /> Assessors <br /> WELL Location 510 E. AA/ Igo 1,-� r7F• Cross Street City Zip 520ZParcel4 <br /> PROPE Y <br /> Owner 3 Address 4100 !�701661 Sheracity LO 8eacln Zip 70801 Phone# 5191-151-'112-0 <br /> e ¢05 <br /> C-57 Contractor Vi Yon It K Lac-• Address 2110 Aolo ms Ayo - City(• KaroZip'7'hS-7;Lic# 123- Phone#510-5`8-764te <br /> Joe Fre tc t.Jds+ <br /> Consultant/Sub Cntr C0y%40V- Address Ctr• st&. Z City 5+v-k+vK Lic# Phone#2.09-Z54-OSI8 <br /> GIS Coordinates:X Y Township ) NO.fk Range G E0-'6+ Section 2- <br /> WORK <br /> WORK TO BE PERFORMED: <br /> ,KNEW WELL/ BORING (CPT, EOPROBE HYDROPUNCH,HAND-AUGER,OTHER') [] DESTRUCTION (choose type below) <br /> �g'•SOILBORING# Z� to DOVER-BORE. DIAMETER <br /> 0 WELL# [] PRESSURE GROUT <br /> 0*Other 1 s� GROUT SPECIFICATIONS <br /> COMMENTS: FroPOSQ Wtiv It oli�cv-stead IrV f FA ll�avL {�I0.tn TQC O. rnn-PS <br /> OV c-ico 41+0-- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA, OF BOREHOLE 2 (1 MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL NA TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE APUSH POINT SGP or CPT)GROUT SEAL PUMPED: 0 Yes [] Nvo1 (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS I�eO•� L,g,M P n't <br /> 0 OTHER 0 OTHER APPROX.BORING DEPTH 20'o,,d ''FOS 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS:8 bori -to IS bortN s +0 2.� b S <br /> NOTE: OFFSI E BORINGS REQUIRE ACCESS AGREEMENT OR ENCR ACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi a'ncees/, I/pules/a d egulations, and all applicable California State Laws. 1! T 7� <br /> Signed x��//l11 /, 1� Title/Company cm4 v- E0.'/ ' IR.�-�NA�eq <br /> Print Name O.X 1 Y�Ic.ri. >rt1�A�S Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: S!0 E • /Y1G tfn' -/iq . ��Ck4v1 <br /> WORK PLAN DATED:--- '4j2 6'3 j <br /> o <br /> Application Accepted By <br /> Date Issued O s a3 Area <br /> p y <br /> Grout Inspection By //l` e a I W•1 Final Inspection By ate <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 290 B9 '�$ 0501171 1 SR# 3 L47j )- <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/30/02 <br />