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map P" <br /> -Hu <br /> WELLERMIT APPLICATION F4ll <br /> EDO SAN JOAQUIN COUNTY MITIGATION <br /> W► L'= ENVIRONMENTAL HEALTH DEPARTMENT (AHD) UNIT IV <br /> 2004 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ' (209) 468-3449 /�� <br /> ENVIRONMENT��N�44(E('WH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �/ <br /> Application is t 9W r 5' No'VrNoaquin 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.Assessors <br /> WELL Location ALyl Tfl �o t N Cross Street City Zip`T 33C Parcel#_ /V R <br /> PROPERTY r�- <br /> Owne��/. r1�. rf�r ,sav y_Address I97L4 7� _City rt�fah Zip952d/ Phone#,Za9– – S <br /> C-57 Contractor_� Address39// .1'td Al-, —City4J.! ,4e ?�64 Lic# !� "�U Phone#9/L 1-71---1d-7--6 <br /> Consultant/Sub CntrTc. c �./ s Address39//•w• �+ 7s Cit;V Ag. c# Phone#_J`/1-37/-�l <br /> GIS Coordinates:X 'y Township Range_1 Section,SW% Sc-�3 <br /> S *7 N w yf� sec- 3 <br /> WORK TO BE PERFORMED: <br /> ANEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) D DESTRUCTION (choose type below) <br /> Z� # U t. o []OVER-BORE. DIAMETER <br /> SOIL BORING <br /> D PRESSURE GROUT <br /> (]WELL# <br /> a"Other Kot / GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING HOLLOW STEM DIA.OF BOREHOLE,y'/ 0 MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: <br /> 17 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL JIPVC D OTHER: <br /> p VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE!OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXIMUM FREE=FALL DEPTH IS 30') <br /> 'SOIL BORING HAND AUGER - GROUT SPECIFICATIONS <br /> 0 OTHER:_[1 OTHER APPROX. BORING DEPTH ll BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed . Title/Companymo;o �gl142- <br /> Print Name oisra Date ti Ou <br /> DEPARTMENT USE ONLY <br /> 001. <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ,r ' <br /> WORK PLAN DATED: //Z'& O 3 <br /> Issued Are <br /> Date Q� <br /> Application Accepted By Da - <br /> Grout Inspection By Date Final Inspection B Date <br /> 66W7 W— <br /> Destruction Inspection By Date bwlf <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT f SERVICE REQUEST# INVOICE <br /> SIR <br /> C-57-A/— WC -WAIVER C-57 Letter of Authorization to sign permitN Encroachment doc P� 9/30/02 <br />