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w- <br /> WELL PERMIT APPLICATION ORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <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 Sari <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San,'Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location fort R-a I Cross Street C:T _ _City Stockl�_on . Zip 5203 Parcel# -030-OI <br /> ;?i <br /> PROPERTYOwner porgy' o f Sta-loom Address 6-. 60; �08� _City SI oC,c�oYt Zip 52b1 Phone# -9'1'6-a-2�-6 <br /> C-57 Contractor - dressCity an Zp149Q4Lic#6363 Phone#_SIp�-I-t{J7 <br /> Consultant l Sub Cntr omaLtr jA Gyts n ddress 14'f kOan si 5 ajS City re s no Lic# 69 38 65 Phone#S 9--a6L X533 <br /> GIS Coordinates:X Y Township W Range 6 E Section <br /> I <br /> WORK TO BE PE MED: <br /> NEW WELL ORING CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) _+ G.� usk) p DESTRUCTION(choose type below) <br /> []SOIL BORING# `�. �oGGCtTOr1S holey � []PREESSSURESURE <br /> GROUT <br /> WELL# �]PR <br /> "Other: Grout Specifications: e r Mt <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE, CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING Q HOLLOW STEM DIA.OF BOREHOLE_10"' MULTIPLE CASINGS?II YES gNO WELL CASING DIA: <br /> [)EXTRACTION ]]AIR HAMMER DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL []PVC ,[]OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS []HOSE <br /> AIR SPARGE gPUSH POINT GROUT SEAL PUMPED: a Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> `,SOIL BORING []HAND AUGER GROUT SPECIFICATIONS:, rleat-= C-_W%atx-t amu± _ <br /> []OTHER: ©OTHER APPROX.BORING DEPTH 50� U BOLTED TRAFFIC BOX or []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 /> r County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x lYbVA6-VI Title/Compan neer eotoc6A eve'D mat r .,C <br /> Print Name Date I a(> 03 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: - <br /> WORK PLAN DATED: ld-Z "d 2 <br /> Application Accepted By Date Issued ��Z 3 Area Q� <br /> Grout Inspection By Date Final Inspection ByCOJKPLZTE ate 'Q 3 <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DAVE;.- PERMIT SERVICE REQUEST# INVOICE <br /> /0 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit-Z-Encroachment doc- 1/25/02 <br />