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F FFG WELL PERMIT APPLICATION FORM SITE <br />qEc SAN JOAQUIN COUNTY MITIGATION <br />R <br />31200 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />MP Gouto 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />N JOPa NMEN�A�N� (209) 468-3449 <br />�P �N�1FtoD�PPR�cM <br />�0�41' kA NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />ApplicatioMilhereby 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 nan'd the Standards of San Joaquin County Environmental Health Department. <br />WELL Location/ S• YG1.Y-ta." " Cross Street S� • 1� (�I fUV1Q� Zi 1s3. Assessors v <br />City p (� Parcel# 196 �- <br />PROPE TY ��\ <br />Owner �l��W\v\� Q ✓ 0� Address %�7 S. � ((t,�� City�rr �Zip�Phon ) 77 + 31; rpm <br />1Tc _9C -57C h Address QSb 3/wive �+�'um PC <br />ity�lanrrZ;p q�irs S40�'Phone# <br />dCA, <br />Consultant / Sub Cntr�,T_-(/SAddress s0 <br />`` Cfty�Lic# SS Phone# 53�•6�6, 600y <br />GIS Coordinates: X YTownship Is Range Section 7 - <br />WORK <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (CPT, GEOPROBE, HY ROPUNCI� HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />`COIL BORING # �- % Ci�-r -z.'"T'3� CP7 !� 0 OVER -BORE. DIAMETER <br />0 WELL # i 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />V'• <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING a HOLLOW STEM DIA. OF BOREHOLE L [] MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />V' <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR [] MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE XPUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS p <br />izAj­ <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 80 f hos 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (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 Ordinances, Rule and Regulations, and all applicable California State Laws. ,L P <br />Signed x c /� / , - Title/Company%�°!h 11494'v' "'� 1 ✓J." <br />Print Name Jtl.D 17.0-,.4 : F. 1 '-,Ld _ RG Date ��/ 2 9 /d y 1 <br />SITE MAP IN UNIT IV FILE, ADDRESS: lS & 690 <br />WORK PLAN DATED: ..�y11;. 3 l 0 <br />/ <br />Application Accepted By ' ] Date Issued ./Y Q Area l T <br />Grout Inspection By Date 1/ Final Inspection By - —Date ,& � a <br />Destruction Inspection By U Date <br />COMMENTS/CO <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY DATE PERMIT / 5 RVICE REQUT # <br />INVOICE <br />-3:50t <br />6' <br />vr�29 <br />s�Y�a SR# 3 ? �'$ `� <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit,____ Encroachment doc_ 9/30/02 <br />