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WELL:PERMITAIPLICAT <br /> ION FM SITE <br /> SAN JOAQUIN COUNTY MITIGATION, <br /> QST �itc ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> UNIT IV, <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 FILE COPY <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 Tide,Chapter 9-1115.3 and the Sttandards of San Joaquin County Environmental Health Department. <br /> WELL Location DYte il? I { "� �' a h Assessor's <br /> ,, Cross Street <br /> _.ty J�, Zip qJr 2 03 Parcel# 4pp�3� <br /> PROPERTY Owner—ED-!i 0 1144- <br /> Qz.�t rl A,flddress .o.k /�2'0o City�btt(�idn ZiPIS201 Phone#21) 1'' 14 -02�{� <br /> C-57 Contractor V i rrO h" ])..114 4- Address 2110 r1#,J a�f�tn5 Ave- City n DR nl�Zip 145 ic#11 D 3 Phone#���-.8 . 7b <br /> Consultant/£i-"rrtrC�¢�yV1t7�1nX C `1�!'"tri.Address_444I!i+Atri �t-L�tf-Cj O�V)D Lic# 83&05 Phone#5� r-264-153 j <br /> GIS Coordinates:X Y Township____ N Range_. �j�. Section V1 16L <br /> WORK TO BE PERFORMED: <br /> NEW WELL BORING(OPT,GEOPROBE,HYDROPUNCH.HAND-AU R,OTH R') 0 DESTRUCTION(choose type below) <br /> 501L BORING# 2 VCA+i t-Kf- 0(i,A. �gjg���t�Ql <br /> OVER-BORE <br /> PRIES <br /> �► S _ 0 P�RESRE GROUT <br /> 1 <br /> COMMENTS lf�y1, �}Grout Specifications:�aAt-Ce4me ed Q �fytyn lbti &W k <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ITORiNG HOLLOW STEM DIA.OF BOREHOLE_ _MULTIPLE CASINGS?0 YES /O WELL CASING DIA: 2// <br /> EXTRACTION 0 Rl <br /> AIR HAMMEDRIVEN CASING THICKNESS TYPE OF CASING: a STEEL /PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERSF p HOSE <br /> 0 AIR SPAR PUSH POINT— GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: t1�w Ca--A t %t �t <br /> 0 O HER: n OTHER APPROX.BORING DEPTH M" 50BOL ED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here), <br /> 'COMMENTS: <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 dgulations, and all applicable California State Laws. <br /> Signed x �� p Title/CompanyItTf <br /> Print Name _ �� F tA4 1 Date " 22EO7- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued r Area " v <br /> i <br /> Grout Inspection By Date Final Inspection B ate <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: I <br /> ACCOUNTING ONLY: AID# FArit <br /> w <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> SR <br /> l <br /> C-57-.._ WC WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br />