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PIPF <br /> WELL PERMIT APPLICATION FUt2M SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EFOC, 2 2 L' <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 I I1EALTH <br /> (209) 468-3449 �� �I�' <br /> `�'" " <br /> %SERVICES <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 /> 7 `+� j Assessor's <br /> WELLLocation 3755 M�1��Vt� !*V�. Cross Street4J���Sq City 5 ��� Zip`7Parcel# (±`l- <br /> PROPERTY Owner CIJ\'^ Address 1P•Q�', &,o, c»L s City 5,,- Ot Zip 7 19 Phone#(-I`( 5Z`8 - (Il 3 <br /> C-57 Contractor tja -Ij 't'j Address P.kZ�. (3 rDK 'W- City k��LIJ+11 ZipW/W}I Lic#-14-"-'�"7 Phone#7't} 77y - `I3k'�C- <br /> Consultant/Sub Contractor AIL �SSyy°� Address (11 Lo✓v �.� ^ City/K--P�"'o Lic# Phone#Z�l 39-5 LtL/ <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: Ij <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) kDESTRUCTION(choose type below) <br /> 0 SOIL BORING# 1310VER-BORE <br /> D WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> c <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE '� MULTIPLE CASINGS?. 'YES ONO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL �s TREMIE TYPE TO BE USED: 0 AUGERS D HOSE <br /> 1AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: kYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: C-Q�W-L,4- <br /> OTHER:AtiJ�N �' THER APPROX.BORING DEPTH �S 0 BOLTED TRAFFIC BOX or i, STOVE PIPE <br /> ASI CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 <br /> and Regulations, and all applicable California State Laws. <br /> Signed x r✓i�"^� V _,Q�1� Title/Company SA.'%`a✓ <br /> Print Name J �-`^t v / Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: :37575 Mon-Foycl Ave n ►1 e <br /> WORK PLAN DATED: Q t1) b r 2 2 o 0 4 <br /> Application Accepted By V LDate Issued De c(f m ber Z3. Z004Area 14Sq <br /> Grout Inspection By �� itis.r,�.� Date C S- Final Inspection By r qn�.t� Date z <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: Z) I U S 1 1 Ca <br /> ACCOUNTING ONLY: AID# =nate <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3502 GO. ov 60. 00 R# ©040'71 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit doe 1/25/02 <br />