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op�M v�l WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />`31 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br />MPR a��N�o�P� (209) 468-3449 <br />CPN �� 40tA R M�N� <br />E14pEPP NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Applicwtm- reby 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 />//' - I <br />WELL Location � SS�f7 So l�l ( 2� Cross Street V S City ZIJA✓b>7 ZipS�Parcel# <br />PROPERT . (aL���- ((���� �'' <br />Owner :;,gtj �L.tif,Q_ pro Addre:rs po Py" 1 KS? City Zipg`TPhone#(%2� �3 � �,3 b0 Xl/ <br />C-57 Contractor6r�lN- Sliv Address950 p`Dure 4C+ -G Cita � �7- Zi�Lic#��'%" Phone 92- )?/.3-.57� <br />{-!`a -t. �y �3! 3a Cb,.w�e.�a��.� w 553 �- 530 �G7� 6 ao $ <br />Consultant 1 Sub Cntr Addressf,N�,g �� CityT Lic#/moi Phone <br />GIS Coordinates: X Y_ _ , Township CS Range -6 ',?!� Section Z 7 <br />WORK TO BE PERFORMED: <br />­�'NEW WELL/ BORING (CPT. G PROBE. HYDROPtJNCH, HAND -AUGER. OTHER*1 f] D ESTRUCTION (choose type below) <br />OIL BORING # C►)7'(� -rte [] OVER -BORE. DIAMETER <br />[] WELL # 0 PRESSURE GROUT <br />[] *Other _ GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />[] MONITORING [I HOLLOW STEM DIA. OF BOREHOLE_ i'_ [] MULTIPLE CASINGS [I MULTI-LEVEL WELL CASING DIA: <br />[I EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: [] STEEL n PVC n OTHER: <br />0 VAPOR [] MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS [] HOSE <br />p 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 />[I OTHER: 0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS:------- —__ <br />-------------- -- — — --- -- <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 Ord' antes, Rules a Regulations, and all applicable Californian State Law"S2- <br />s. Signed x (•'_� Title/Company_/PrintName1-�� G�-K T lam& �d �(-7 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: /;-13 r l v <br />Application Accepted By- Date Issued Area / <br />Grout Inspection By Date— Final Inspection By Date <br />Destruction Inspection By / l Date UT <br />COMMENTS I CONDITIONS: <br />VN <br />ACCOUNTING ONLY: <br />-ui_ <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PE ICE REQ EST <br />INVOICE <br />3S6 <br />SR#OD3?I <br />WC --WAIVER C-57 Letter of Authorization to sign permit_ oc^ 9/30/02 <br />