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WELLSERMIT APPLICATION FIRM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <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 />Z3%S �v %rZnt L-i�i PA JoL �cnbi: �537� arcel#AssessorZ(LI-02-00 <br />WELL Location Cross Street �'nrL' wa1� City rl t•C�� Zip <br />PROPERTY Owner S Vve Pr�)AvG+S Address -2641' S w11-'If"j" 0A City LnrSc.1, L-A Zip ` CWiU Phone# <br />\ -, <br />C-57 Contractor C�"e,1 �, .�d�-S. * tr Address yJ� l�l�•.,.e Rd City '�o•r}%�c'-Z ZipyWS )Lic# C-3-7- <br />�S�yc7Phone# ('?2s) 31 3--OQ <br />"�P-elACk0 <br />Consultant / Sub Cntr-ScCbt; fin+ �' wG'f C-4dress 3611 -e 1 0�f� City Cc,­8c,�, c. Lic# b S4 Phone# (�{ lb �� I OyL C <br />.iP i0 <br />GIS Coordinates: X , Y <br />Township. <br />o;'Tl\ Range -(:; G; 0 SI - <br />Section 19 <br />WORK TO BE PERFORMED: <br />XNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) [] DESTRUCTION (choose type below) <br />SOIL BORING # (-PT-2— [] OVER -BORE. DIAMETER <br />[] WELL # [] PRESSURE GROUT <br />[] *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />[] MONITORING [] HOLLOW STEM DIA. OF BOREHOLE Z [] MULTIPLE CASINGS [] MULTI-LEVEL WELL CASING DIA: <br />[] EXTRACTION [] AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: [] STEEL [] PVC [] OTHER: <br />[] VAPOR [] MUD ROTARY DEPTH OF GROUT SEAL C TREMIE TYPE TO BE USED: [] AUGERS ,( HOSE <br />[] AIR SPARGE/ OZONE .PUSH POINT (GP orCPT) ROUT SEAL PUMPED: KYes [] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING [] HAND AUGER GROUT SPECIFICATIONS <br />[] OTHER: [] OTH <br />APPROX. BORING DEPTH SSC [] BOLTED TRAFFIC BOX or [] STOVE PIPE <br />CONDUCTOR CASING PROPOSED VO (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company f" -O t e Ct %e-Cka,3 • `5, - SCC--O� <br />Print Name (Sf ILt4\ C area Date -7/cfkg <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 1 _--1 <br />WORK PLAN DATED: <br />Application Accepted By , 'r� ��� Date Issued -74 3C 11 C"' Are 4,Z l C <br />Grout Inspection BC Date Z Final Inspection By Date Z ` <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />rr <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE QUE # <br />INVOICE <br />SR#0)3 (1012-2 <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit Encroac ment doc 9/30/02 <br />