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WELL .-IERMIT APPLICATION FORM 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. O19 -oto --5(. <br /> q Assessor'sO19'ow. 5 <br /> WELL Location 19S-5-5' I`'TVLftC> Cross Street E.OAMof ity LOCK EFo2LEip gSZ3'fParcel# 1 1? e!510- Z 1 <br /> PROPERTY Owner V004 LA(S*LORAuvE, W/NN Address 19 SS 5- Al. Tv LL Y CityL0C04:'0 .D Zip957-3}Phone# 3'2 SS 3 t <br /> C-57 Contractor Address 1 1 �`: '1�i i i�'�'��'.'` City f°� .c��-�Zip sic#1 Phone# .69-53 BYO <br /> Consultant/Sub Cntr URAddress 3+45-!a.5NA'y AVE City E5S5NoLic# Phone#SS")-Z-4I • 10�j-3 <br /> Svt 7£ 10 1 <br /> GIS Coordinates:X Y Township_ �{ N Range � E Section 3Oat 3 I <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION(choose type below) <br /> `,SOIL BORING# ZI LMNrnNSyPWOM4-Sot L. !%00e pL,n-'Cr 0 OVER-BORE <br /> B WELL# 0 PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> B MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE -Z MULTIPLE CASINGS?B YES %40 WELL CASING DIA: <br /> B EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: B STEEL B PVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> B AIR SPARGE PUSH POINT GROUT SEAL PUMPED: B Yes 'JNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> `dSOIL BORING B HAND AUGER GROUT SPECIFICATIONS: C£r*14 rtrf �$4ry1'on+17� 30TToM TVD Sart�tG�. f�5 <br /> /B OTHER:_0 OTHER APPROX.BORING DEPTH L -319 B BOLTED TRAFFIC BOX or B STOVE S-D4.0 <br /> CONDUCTOR CASING PROPOSED? /V O (if YES,list specifications here): <br /> *COMMENTS: 2 ( MoLt5 Fol- SorL Aa1rD VO4tPort C-LLtGriorV Lsp ro /S 1 3G 5 �SSl3LY Oti£. drZ_ <br /> -r-U­'0 Flo Lt,5 r,, 3 S r <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, ules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company_ Qv 47tz-Yme— TEG <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted B v'L L_ i Date Issued 7 6 17 Z <br /> � _ �p ` � Area <br /> Grout Inspection By ^ � C Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> cer^* <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57_ WC=WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br />