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sk r. FILE COPY <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 /> 5/6 N PPr.#d& city st p Assessors) <br /> WELL Location AveQ V e Grass Street�U G 5 C' Zi 9.52/S Pare Da..130 ' O 2^ <br /> PROPERTY PERS 1"L, 1 <br /> Owne+�a�klttin[I TC SJOr _Address s Cloud��CW —City Wafsnnv,jleZip 9Sd716Phone# 31-71 3203 <br /> c-57 ContractorCnv;ra C-: o5t Address 3 �PJ Cityl3Le,, ZipjZ921 LidFG&V27Phone# -�!L -f[b� <br /> y Consultant 1 Sub CntrA G E Address S 3j�,) _ _City STK Licit(Yd P 3 7 Phone#-;?Of'&7-/ooG <br /> GIS Coordinates:X Y —,Township Range Section <br /> WORK TO BE PERFORMED: { <br /> ,j(,dEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) DESTRUCTION (choose type below) <br /> SOIL BORING# r —/5 Q OVER-BORE. DIAMETER <br /> a WELL# 0 PRESSURE GROUT <br /> p'OtherA GROUT SPECIFICATIONS <br /> COMMENTS: ea e t `-1 ' 4 lint Are, 0 9 SQ IL 4ep". <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 11 MONITORING Il HOLLOW STEM DIA.OF BOREHOLE I. n MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> p EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS A TYPE OF CASING: a STEEL U PVC Q OTHER: <br /> fl VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL YD TREMIE TYPE TO BE USED: JGAUGERS p HOSE <br /> AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes %No (NOTE: MP /MUM REE-FALL DEPTH IS 30') <br /> SOIL BORING 13 HAND AUGER GROUT SPECIFICATIONS Igor+ and -¢ 0-Ja <br /> OTHER: rl OTHER APPROX.BORING DEPTH �I j]BOLTED TRAFFIC BOX or 0 STCVE PIPE <br /> CONDUCTOR CASING PROPgSED N-4 (if YES,list specifications in comment section) <br /> COMMENTS: Of e% Q rj +_0 14 �, Ll w" L•. <br /> NOTE: OFFSI E BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING FOURS 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 n Rules and Regulations, and all applicable California State Laws. ,1 ! /� <br /> Signed z Titte1Company en+- f O r A vRN c r!•d' ('e, <br /> Print Name C_:�Ir,s Ino ker ."� 1 a r Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: .� A) <br /> WORK PLAN DATED: <br /> Application Accepted By Date issued Z3—0 Area 0GR V <br /> Grout Inspection By. Date Final Inspection By t tri to b <br /> Destruction Inspection By Date — <br /> COMMENTS 1 CONDITIONS: — <br /> ACCOUNTING ONLY: AID# FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKi_ <br /> REC-D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 2ab(v 2- 3-15 SR# <br /> C-57 WC -WATVEP C-57 Letter of Authorization to sign permitA Encroachment doc 9/30/02 <br />