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WELLPERMIT APPLICATION ARMSITE <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. <br />��e r:..nhc Assessors <br />WELL Location 36C �'y' =n+ ]-� ��c� Cross Street ;' Kw V CitvTroCq Zip `I '�3 )6 Parcel# 2-18 <br />PROPERTY Owner -7-GIC- e0\, -7-o'C. Address �� ��X 71I City baIIitS,TX zip7S2L1 Phone# <br />Q 7 I <br />C-57 Contractor LIe(r) 1 �-Si� V Address ��k i4%)vv- p� 4SS City,11ar+�iReZZip is#(,S-,4o7Phone# <br />fzo'\C No <br />Consultant/ Sub CntrSE-CCQ 4-(,�eFrtA` W,\-IAddress30i7K (4A,Sle City Cc --,A c.-) Lic#'aS4`iL1$7 Phone# ��I6�SEi/'C1►L1C' <br />too, I � <br />GIS Coordinates: X Y Township Z S0, -T Range S C r yr - Section <br />WORK TO BE PERFORMED: <br />,NEW WELL / BORING JCPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') <br />'gSOIL BORING # CP 'I-1 <br />[] WELL # <br />[] 'Other <br />COMMENTS: <br />[] DESTRUCTION (choose type below) <br />[] OVER -BORE. DIAMETER <br />[] PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />[] MONITORING [] HOLLOW STEM DIA. OF BOREHOLE [] 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 TREMIE TYPE TO BE USED: [] AUGERS R'HOSE <br />[] AIR SPARGE/ OZONE PUSH POINT (GP or CPT) GROUT SEAL PUMPED: XYes [] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING [] HAND AUGER GROUT SPECIFICATIONS <br />[] OTHER: [] OTHER APPROX. BORING DEPTH C [] BOLTED TRAFFIC BOX or [] STOVE PIPE <br />CONDUCTOR CASING PROPOSED JV ; (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 />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County O(�"-` rdinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x 1— rd_-Title/Company }arc t e L� & ectoli i S - S I L O <br />Print Name V\ C n I -f'4 ✓ Date 7 JCfl bq <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: ' C (:/;Ir, +7 - <br />WORK PLAN DATED: <br />Application Accepted By l,j \ « 'c Date Issued 7 -Z-0 nY Area Z <br />Grout Inspection By _Date O"L Final Inspection By Date FS2 COZ- <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />01 <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />X5`1, ou <br />S i 3ZzT <br />( <br />-,t,�oo`( <br />SR# " c( C 1 I <br />C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachmen 9/30/02 <br />S�oo3���t <br />