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WELL cRMIT APPLICATION FO`K141 SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 96202 <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 andlor install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the StandardsRf San Joaquin County Environmental Health Department. <br /> '` �flfly- Vr. F r Assessor's <br /> WELL Location R�r7 f '-L ass Street Cfh `fT= city S��C K7PI)Zip Parcel# <br /> PROPERTY Owner��n1 �� �'�r �iJ1iR �c w4i`-Address f, 0. �'�J� t'�a 7 City5TCCtgTDn__Zip9SZ") Phone# 204 t165 3YZ <br /> C-57 Contractor I')1j',J.h Address 5�y6o S, �11� % 4bQ_City5 �?!F► Lipq Zai Lic#rn7�Phone# �1 �3lr e3 <br /> Consultant/Sub Cntr _&G, F- -1 -Address-8'3 s0-1\,j-�9,J, City. f nn Lic#/b5-4do?7 Phone#(Z�>V V4 - f(�n <br /> GIS Coordinates:X Y Township Range lU Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> '*WELL# Ef W- r} -�� PRESSURE GROUT <br /> 'Other: Grout Specifications: `�'QIr71 9a 0 1 y� <br /> COMMENTS Sr-F^dp'PRtiv'�Q wer< PAnl nA-m n 19PR1 -- !E?A n �g __--- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE I5 MULTIPLE CASINGS?I]MULTI-LEVEL?© WELL CASING DIA: <br /> Soho ka EXTRACTION <br /> Q AIR HAMMER/DRIVEN CASING THICKNESSP��_TYPE OF CASING: []STEEL PVC a OTHER: <br />` a VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL ]M'- �3S'TkMIETWE TO BE U E AUGERS l]HOSE <br /> a AIR SPARGE I Ozone 0 PUSH POINT GROUT SEAL PUMPED: esp a No (NOTE: MAXIMUM FREE-FALL.DEPTH IS 30') <br /> (1 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 7 0f'7/ <br /> 0 OTHER:_n OTHER APPROX.BORING DEPTH ,BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> r CONDUCTOR CASING PROPOSED?�J (if YES,list specifications here): <br /> 'COMMENTS: S F!�A ' ; T� inlo K v1 D?7�Z� �6 �y Q� Zfl� <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 Ord" antes, Rule and Regulations, and all applicable Californ' tate Laws. <br /> Signed x 1 Title/Company c) ✓`-Cr <br /> - <br /> Print Name J. v�J� Date 01-10.343 <br /> DEPARTMENT USE ONLY <br /> SITE MAP 1N UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By �� Date Issued G1/� J Area <br /> Grout Inspection 8y ( ate r mal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: gl (7' <br /> ACCOUNTING ONLY: AID# <br /> i <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R CgAY/ DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1-7 <br /> I <br /> C-57_ WC -WAIVER C-57 Letter of Author o sign permit Encroachment doc 8/29/02 <br />