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WELL PERMIT APPLICATION 09RM 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 /> Assessors ti <br /> WELL Location 3? � lv cross street �% o R5 city ?race Zip Parcel#_ rtH 71)-30 <br /> PROPERTY Owner al K 0RILL Address 1W P•ST64nd City f&tsIrxr Zip 770 6 Phone# <br /> C-57ContractorQ IZtit111G _Address OWC City f1SLZ Zapg'i55Lic#yE516�Phone#gets-3r3-58�? <br /> Consultant/Sub Cntr��lY1�7i��a Address .0•�D City�Savtowta Lic# Phone#7�7'933-�3C/ <br /> GIS Coordinates X Y-1 JpT <br /> ,Tri p71� 1 'rl�[LERange Section <br /> WORK TO BE PERFORMED <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HA*]E* P40j0@9') DESTRUCTION (choose type below) <br /> SOIL BORING# []OVER-BORE DIAMETER <br /> Q WELL# E-NV12u'�,IMEs 71:F �:EALTH GROUT 5 ECIF C7AONST rip Cat IM9 <br /> p Other €'ERIAT/GPhVIGES <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0HOLLOW STEM DIA OF BOREHOLE_,. []MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA <br /> EXTRACTION d AIR HAMMER/DRIVEN CASING THICKNESS '1 TYPE OF CASING STEEL []PVC 0 OTHER <br /> APon d MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED I]AUGERS 0HOSE <br /> 4IR SPARGE/OZONE []PUSH POINT(GP or CPT)GROUT SEAL PUMPED WYes p No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING []HAND AUGER GROUT SPECIFICATIONS U — <br /> XOTHER �0 OTHER U 1/, D APPROX BORING DEPTH 115 a BOLTED TRAFFIC BOX or 0 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 Ordinance les a egulations,and all applicable California State Laws <br /> Signed x Title/Company <br /> Print Name Dale ` �►� 3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED' <br /> Application Accepted By �"'�r""" ` ` Date Issued ?-//a/Ift 3 Area LANP f <br /> 17 <br /> Grout Inspection By Date 2 Final Inspection Bynnnre ^ Date O <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIIONS !� - <br /> ACCOUNTING ONLY AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE MIT/SERVICE REQUEST# INVOICE <br /> 131Cbf'-2 1 60' 1 60" SR# p 0-12--2 o <br /> C-57 WC -WAIVER C-57 letter of Authorization to sign permitEncroachment doc 9/30/02 <br />