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WELL_ PERMIT APPLICATION FOR. <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br /> <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br />ORIGINAL <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 Joaqu n County <br />Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location °.- S Cross StreetYete ("2---ity dVl Zip Parcel# <br />PROPERTY Owner Address I/Oo kv'c het(6ericrty -5 zip9yhone# goo elle0y-icisy <br />C-57 Contractor 141-?& Addrese32-530:74.1- 4-/Gety e6le42) zirW7VALich55(1414hone# eiMP 613f - 7276 <br />Consultant / Sub Contractor 4 C-- Address 8'2? 5114u.j gecity S7le_illuc# - Phone# Y4 7 1-zo4 <br />GIS Coordinates: X Y , Township Range Section <br />0 DESTRUCTION (choose type below) <br />OVER-BORE <br />PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS: <br />TYPE-OF WELL INSTALLATION TYPE <br />)3,1fOILOW STEM <br />CONSTRUCTION SPECIFICATIONS <br />ONITORING <br /> <br />DIA. OF BOREHOLEgliMi i MULTIPLE CASINGS? 0 YES ,frt0 WELL CASING DIA: <br />)3"6TRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ."' TYPE OF CASING:93/STEEL ,4 PVC 0 OTHER: <br />El VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL &C-7.--- TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: a Yes jj-trlb (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />['SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Po a --4 - tL._ ---z----/---- <br />0 OTHER: 0 OTHER APPROX BORING DEPTH 3t.) Fe-e-T—...„13-80.1TED TRAFFIC BOX or [I STOVE PIPE <br />*COMMENTS: <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />/4 thl.:4"-"tle---41 / 3 — e4-5 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />Assessor's <br />V <br />ir <br />k< TO BE PERFORMED: <br />EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER`) <br />SOIL BORING # <br />0 WELL # <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 County Ordinances, <br />Rules and Regulations, and all applicable California State Laws. <br />Signed x Lge46--- Title/Company S <br />Print Name W ww--- 1-T71 (-7, Date ,42/ <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: Z-2--3e4 <br />WORK PLAN DATED: Tut"e. /( <br />Application Accepted By <br />Grout Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: <br />(-1 C: <br />Date Issued <br /> <br />Final Inspection By <br />Area <br />Date <br />ACCOUNTING ONLY: AID# FAC# C ------`5"R 60 .t Cr 706— ) <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PEI.-2-A--ff / SE VICE—Rttquts $T-T--------1NVOICE ----RIT <br />25-7. /SI CI goD to 16 ,4,V C'fl.. /2- 2- SR# 297e , 5 <br />C-57 Letter of Authorization to sign permit y. Encroachment doc 1/25/02 C-57 WC -WAIVER