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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 SEP 0 3 2002 <br /> (209) 468-3449 <br /> NON-REto coFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH <br /> Application is hereby made to San Joaquin County for a permitnstruct and/or install the work described. This application is rM"IRNA ,QS,San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County.Invironmental Health Department.Assessoes C I Ty OG <br /> WELL Location7�'���I�� uS// �eA10M foss Stree ��£6 O City I-•aJr;A� g Zips 5330 Parcel# <br /> c �c _ I L nRmr) City�c ZIP`? S3 Phone# <br /> PROPERTY Ovmerl7P�ey'« �- ci: sll4ehIddress `J <br /> sN,=C11 <br /> C-57 Contractor C`. o__ a or'd�S�_Aodress qrA �r+`G �8 • City Mnrkir�Gz Zip gN55o Lic# y45t65 Phone#9a5-313-5800 <br /> Consultant/Sub—Contractor URS noal-�n n _Addressa A'10 C..&1-�4L ibn City S o-aroa'�h Lic# Phone# a lb'b�l'a0o0 <br /> 5u + 300 <br /> GIS Coordinates:X <br /> y.,TownshipRange Section <br /> WO K TO BE PERFORMED: HAND-AUGER,OTHER*) 0 DESTRUCTION(choose type below) <br /> jiTEW WELL/BORING(CPT,SOIL BORINGI#'DROPUNCH, , 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> Grout Specifications: St_ ) lQs,� <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> See a�*c ct�neA fable r <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLES MULTIPLE CASINGS?gAES NO WELL CASING DIA: P <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSh•ScTYPE OF CASING: .0 STEEL Fi'P qvG OTHER: <br /> o <br /> VAPOR MOUD ROTARY DEPTH OF GROUT SEAL V art CS TREMIE TYPE TO BE USED. UGERS a HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: .0X€s 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 1-1 i E-V d A-'A 3'( b G�-lor:le.. Prix r <br /> W6THER: (ezulc' 0 OTHER APPROX.BORING DEPTH-110—res WLTED TRAFFIC BOX or 0 STOVE PIPE _ <br /> CONDUCTOR CASING PROPOSED? Ll � (if YES,list specifications here)* <br /> - <br /> -COMMENTS: '�,e e.. OC-N-A c9n e19. -Irc <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 /> f <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 <br /> DState <br /> vLaws. J/ <br /> /�/ Title/Company/F-T'V"'/ /�f/7r'n�^-/UQS 4�h'y <br /> Signed x� cc <br /> Print Name P <br /> IC qAgjD ✓fW AyL47 _ Date 0' Z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> pted B /�/ }O� Date Issued �IOZ Area <br /> 144A^ ®S <br /> Application Acceyc �i to <br /> � l_TT2, <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# �erx <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT ISE VICE REQUEST# INVOICE <br /> (!Yy Clic 9 502 SR# Obi//d� <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 1/25/02 <br />