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WELL PERMIT APPLICATION FORM SITE <br /> ` ''IhG'it�1i N F�;i. �IEAI.1 H SAN JOAQUIN COUNTY MITIGATION <br /> PFI1'1$1 F 1%WFZONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 03 JUL -9 An EI eeber, Third Floor, Stockton, CA., 95202 <br /> 00 (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROWDATE 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 /> /U6-1 L{ I 45337 Assessors <br /> VOECC Location I[.i LI h h)�?'L' Cross Street +� ���+ City f 1'✓1Lt.(t_`, Zip Parcel# <br /> pp <br /> 6 <br /> zv9- 1'/ 7 <br /> PROPERTY ner�U� tti/v11G:�'�1 E� ('.t( O��Addrresst�lcM, �- �hOY4 J- City�i Eck�UYI Zip��l�S Phone# <br /> C-57Contracor � Address � City Zip�fS53Lic#�5i(v� Pho #5-3/3-5trc1Q <br /> l n�u lksllf'� aILI LL--e r<<�1Z FI C)tklood �(/, 1i -✓11 3 '-floe` <br /> Consultant ub Cntr Ct&"1, �Y- Address City Lic# Phone <br /> Lr <br /> GIS Coordinates:X Y Township -�J Range b,C- Section 35 <br /> WORK TO BE PERFORMED: <br /> A NEQW—W—EL-L rBORING (CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") g DESTRUCTION (choose type below) <br /> SOIL BOF- �(,1x-�')1C1/7%-11,6r/IX-IZ ,0OVER-BORE. DIAMETER <br /> WELL# ORESSURE GROUT <br /> a*Other cc GROUT SPECIFICATIONS <br /> COMMENTS:f{ r Vitt Ciu 'A' j ktj <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONSINa <br /> 0 MONITORING JHOLLOW STEM DIA.OF BOREHOLE ' "a MULTIPLE CASINGS 0 MULTI-LEVEL �LL CASI�c� <br /> NG DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER:-1/4 <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAJ I,1 I I-I-ei L k(4I TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 'D;Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS __ <br /> 0 OTHER: �,OTHER_ APPROX.BORING DEPTH _�K _0-BOLTEaTRAFFIC BOX or-Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED ISI (if YES,list specifications in comment section) <br /> COMM ENTSA,�1I1 V3Acn�1--' Wtftkc i tij i�vgouh'll(AliI Y`LI .(d1 (LL;r-li iNl la�) ,'0.U4f'.-n/rr- Sow0lt�S. <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 Or inances, Rules and Regulations, and all applicable California State Laws. <br /> �/�Signed x G ' Title/Compan ' a/ <br /> Print N e �e/���' ���'�//n U�� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: C✓ AJ OC- � tU.P, rlx?nAV-U � <br /> Application Accepted By/ I/Pt A� I Date Issued �I/�]I �� Area <br /> Grout Inspection By f t Date t 310 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> / , D l i6- 7 / 0� S R# r>D (,--? <br /> C-57_ WC=WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />