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'-WELL PERMIT APPLICATION ARM <br />SITE <br />SAN JOAQUIN COUNTY MITIGATION <br />AVIRONMENTAL 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 />Assessors <br />WELL Location L 360 W P S t G ��c1✓� �-i �� Cross Street) oL �o,nh� P�. City _T �tiL Zip tS3 Parcel# L3 lel u u <br />PROPERTY <br />Owner -I - Gt evP-A, -VAC- Address P, o, 9GX 1 [ ] City �q �,uS� T%` Zip SZ 24 Phone# <br />Raticl.O <br />C-57 ContractorCCISCA60- P-)(-;0, rx5 Address 5A22 D(r4e�r_ Gi r CityCc dovq Zi0ls)t12Lic#jjSI% Phone#- (9I�)638-11 9 <br />Consultant/ Sub Cntr S�z—C-OR-t%A4rnA*'104ddress30(7 CityP'1+-LkO Lic#6sl,IH4? Phone# 016)961-VLf0D <br />S*I-e--U camC 74 <br />— I <br />GIS Coordinates: X 'Y , Township_ ZS Range SJ1 Section <br />WORK TO BE PERFORMED: <br />ANEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") <br />[] SOIL BORING # <br />WELL# MW -1 thrc .}� i�W �, �w-LI-) <br />[] `Other <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />MONITORING <br />HOLLOW STEM <br />[] EXTRACTION <br />[] AIR HAMMER/DRIVEN <br />[] VAPOR <br />[] MUD ROTARY <br />[] DESTRUCTION (choose type below) <br />[] OVER -BORE. DIAMETER <br />[] PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />Cy <br />CONSTRUCTION SPECIFICATIONS ij C - <br />DIA. OF BOREHOLE [] MULTIPLE CASINGS [] MULTI-LEVEL WELL CASING DIA: 21) C) <br />CASING THICKNESSSGS TYPE OF CASING: A STEEL R PVC [] OTHER: !, <br />DEPTH OF GROUT SEAL 3 TREMIE TYPE TO BE USED: XAUGERS [] HOSE .L <br />[] AIR SPARGE/ OZONE [] PUSH POINT (GP or CPT) GROUT SEAL PUMPED: [] Yes )(No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30) <br />[] SOIL BORING [] HAND AUGER GROUT SPECIFICATIONS <br />�7 tiH ow <br />[] OTHER: [j OTHER APPROX. BORING DEPTH [> OBOLTED TRAFFIC BOX or [] STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />rf <br />COMMENTS: N1 �nf- (, i� = IS c� iq • hc,rel.ale, t0,r of pct, 5}��{ C c�1�vCic�� CaS Imo, �dcrr\ ®-3O 1D�t S a %+ o�+ Seel �S �vrnP l <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x�Title/Compantqr6zct Cie lob+S1�/'SEGo2 ��n�unG I i0 1at <br />Print Name �r' i UA Cai-e Date j0/ !/03 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: -6 It -2-fo 3 rn,, <br />Application Accepted By r Date Issued 10 1 ( Area <br />Grout Inspection By L ,,,���,.., Date JC Jb 0'? Final Inspection By Date D <br />Destruction Inspection By Date pp <br />COMMENTS / CONDITIONS: rn7E rlti'l� tet, ems-, �� tlil , <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />UEST # <br />INVOICE <br />5 S� <br />Ss-cf.00 <br />cSOSfl, <br />GHQ <br />Io / 03 <br />SR 1�5� S Z� <br />C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroac men oc 9/30/02 <br />