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E E E ID' WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />JAN 12 2001 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />Pr:R�AIT/SFR\nr,FS (209) 468-3449 <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />N - G�% 5 <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 I�-' (�'-t�%%may d4,42 ,13C K� Cross street/-CAA;t4UA � 4V=City Sj c`C:iC%f�, -t Zip /� v Parcel# <br />PROPERTY <br />Owner Address?,(). ACk CityJli!XltTClw Zip1,5�41iPhone# <br />C-57 ContractorUP_X_& Address //C)st!C &42) City/17agaj A,CZZip SJ 3Lic#'' hone# Cl;?5 CI;?3/3 -_S-60t' <br />Consultant/ Sub Cntr SECC.0 Z iN 1.)1�.iddress _3(-i "7 K/"FO.CE P ---b City/i(cP- R Dc# Phone#(,�/6-)&- (�) <br />GIS Coordinates: <br />WORK TO BE PERFORMED: <br />ANEW WELL / BORING CPT, GEOPRO <br />MSOIL BORING #'&1 2)r12eFC_7 <br />COMM <br />Township <br />ROPUNCH, HAND -AUGER, OTHER*) <br />-A-rl4ti <br />Range <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE, DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 'SHOLLOW STEM DIA. OF BOREHOLE /Z!/ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />k'EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS5(_A, D U. �I bYPE OF CASING: 0 STEEL �&VC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL-- 3'/ ' TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br />0 AIR SPARGE/ OZONE 'jPUSH POINT (GP or CPT)GROUT SEAL PUMPED: A Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS '�� 5 /r its /L'r�C� 36A %UN'i TC — <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH y�� r167 J 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, Rules and Regulations, and all applicable California State Laws. <br />Signedi`'��� ��i6- �— Title/CompanyCCLy�- <br />Print Name Date 0/ le)'�/ <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: lZ� ZS'ro3 <br />Application Accepted <br />Grout Inspection <br />Destruction Inspection <br />COMMENTS / CONDITIONS: <br />Date Final Inspection <br />Date <br />/ . <br />� '' - ... <br />W — �i <br />ct- <br />/IxT� <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE <br />PICE REQUEST # <br />INVOICE <br />C -57J WC v' -WAIVER_ C-57 Letter of Authorization to sign permit ✓ Encroa hment doc 9/30/02 <br />