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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) u U <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 SEP 0 3 2002 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVROf�MEN I HEALTH <br /> Application is hereby made to San Joaquin County fora permit to construct and/or install the work described. This application is � �San <br /> Assessors L <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County nvironmenlal Health Department. <br /> / 5��'Ga�' r15330 Parcel# AATNR-oP� <br /> WELL Locatio'spdo'QI►(C}40VS/elti.-'wL 0'A ross Street4�7(�-I�• City—��t zip <br /> -r�_I.,:..cn 1 _,,;c 4�c S A4-,cf, ress a51,m (fir\eme nRcrrl City �r ZiPy <br /> PROPERTY Owner ,mac• J <br /> n� 11aw• (Z8 - Cityla r ,i Zipgk55.; Lic# yR`_�65 Phone#99;35-3t3-SY�y <br /> C-57 Contractor1\��cmd"reS"Address <br /> Consultand Sub Contractor QRS Co. r 4, Address2 R'roC \tL'ay kQ2 SIkCity Sasract�^ Lic# Phone# dttb-b�d-�c=cam <br /> 3Co Section <br /> Township Range <br /> GIS Coordinates:X 'Y�--' <br /> wo K TO BE PERFORMED: o DESTRUCTION (choose type below) <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,UAND-AUGER,OTHER') a OVER , <br /> D SOIL BORING# o PRESSURE GROUT <br /> DWELL# <br /> Grout Specifications: SCe `2\0.:> <br /> -Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �S2e adhc_c4ed <br /> �-- <br /> LI MONITORING D HOLLOW STEM DIA.OF BOREHOLE 13 MULTIPLE CASINGS?ARES ONO WELL COTHERDIA: ` <br /> 17 EXTRACTION 0 AIR HAMMER/DRIVEN DEPTH OF GROUT SEAL V eS PE OTREM EI TYP E O BE USSTEEL D pvC-UGERS 0 HOSE <br /> 0 VAPOR a PUS ROTARY <br /> PUSH POINT GROUT SEAL PUMPED: [�s p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> A AIR SPARGE 3°In bt'.r\�wi•�' tr•`� <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: �'tPe 2''S Po -E\o.r� -ah <br /> �THER:Pie2A APPROX.BORING DEPTHgo-rQ-S A,SbLTED TRAFFIC BOX or STOVE PIPE <br /> OTHER <br /> CONDUCTOR CASING PROPOSED? is`' (if YES,list specifications here): <br /> 'COMMENTS: ee �^ ` <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 accordance with San Joaquin <br /> County Ordinances, Rules an egulations, and all applicable California Stat�erLaws. <br /> 1UQS <br /> ` � Tide/Company��` c /hiQ7✓✓ If/ <br /> Signed x <br /> ✓ilA/ AYE Dale 2 -D � <br /> Print Name / DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> p,Q Date Issued �T�OZ Area <br /> Application Accepted By r Date!I I Z <br /> Gout Inspection By <br /> Date Final Inspection By /�K^^-�"u <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# cere <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C�LfD/ — //T11 /( 9�soZ SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> 1/25/0 <br />