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WELL PERMIT APPLICATION FOR <br /> SITE <br /> HfISAIRPOAQUIN COUNTY MITIGATION <br /> ttN!Vihbh'MtNTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 03 A04 f- W ljip I,jhird Floor, Stockton, CA., 95202 <br /> �n (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 /> 17y 4"'L �/��) �, I 1 Assessors <br /> L Location 1 Ijn;�A 7j �jI_ Cross Street �1 y �c1 City i' Zi �J 3 Parcel# <br /> PR&RTY Ownet hetlt(L) B �rV#A3 ddresss iq 1� C— (tV1f kV_ ��ct�r s Zips G`) Pho e# <br /> C 57 ContractoP{J L'V1Q 1t '•S�r1t�.1 f� Address F_A_S� CitwG,�IUj Zip 1�G Lice z Pho eta <br /> consultant 1 4 2 cSubCntr' CUlatt-x ' �VU �t4cldres�""l i tyLAdC( IKLic#t�4 Phone <br /> GIS Coordinates:X Y Township J� Range Section�t� <br /> WORK TO BE PERFORMEM <br /> [] NEW WELL/ ORING (CPT,GEOPROBE,HYDr^-i INCH,HAND-AUGER,OTHER-) \DESTRUCTION (choose type below) <br /> `SOIL BO L Y, Y S•S -_I CJ r- [ OVER-BORE. DIAMETER <br /> //[]WELL# PRESSURE GROUT <br /> �Other '- , - ��� �r_a� V.7 it ,��j GROUT SPECIFICATIONS <br /> COMMENTS: 0 a Ibow'A-�L X4411Z�E��v d�e�ktiL" A Litt � �� (,ti U� - LP��V — L Z Z- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS NC' 1 i�" �' '�U(A U•1\-,6)11i t,`�x•LI Ott' i IqS <br /> []MONITORING []HOLLOW STEM DIA.OF BOREHOLE "[]MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: <br /> [] EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYf? OCASING: []STEEL []PVC []OTHER: 44 <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAM ke, ft 4� afREMIE TYPE TO BE USED: []AUGERS []HOSE <br /> []AIR SPARGE/OZONE []PUSH POINT(GP or CPT)GROUT SEAL PUMPED: XYes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> rOIL BORING []HAND AUGER GROUT SPECIFICATIONS <br /> []OTHER: d�OTHER 433/1 APPROX.BORING DEPTH /.() �(_� t []BOLTED TRAFFIC BOX or []STOVE PIPE <br /> . iN <br /> 'kfi J't ttl�J �.� �S �(aW1�ONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: Ly1 D1�lC Ca ] (�Ii�IlillA�-Pa��`t - (G� I-t CLI�C(� �xtl 'GIT C1 �VC1lytG�.1 �1i � `�CtVh Q�G <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 O/r'di ances, R . es and Reguyla�tions, and all applicable California State La/w,s. ,/ / <br /> Signed x `� ?iLtc,1 �12�t}r Ul Title/Company�/�' G�t /7 �/�7J 1. UQ)LlY 1,f Liu�/11Cjl�C <br /> Print In <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: C L'1.� LIJ 62 C(; <br /> Application Accepted By ! I` � Date Issued 7��� Area ^_ )fl 7_ <br /> Grout Inspection By Date 7117 1 b"> 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 /> la1-6k �f SR# 3060 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />