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(11464 MLR <br />MITIGATION <br />UNIT IV <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />(--)414 °(-) 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 />(.19AhL Assessor's <br />WELL Location CD 9 2 I C0/4rNL A/Z • Cross Street rlioAnirC,4-\ Al' City P zp (15.?Y 5 Parcel# 055- 3z - <br />PROPERTY Owner ;C../MAD Kip,) Address P 0. gc4X /SW City tA/ „ d,b,;4 Zpq 5Z,Er. Phone# t<S1 ...3,7 (133 tO <br /> Address g 3 -7 Si-I 4 oa 0 city --S7.9(Kfralp 9 zo)-- Licit icsaz 7Phone/4 19 o lc <br /> Address 13 7 St4hvy A D City 57-cC)(7-"Lic# •95iNE Phone# (16 7-i 6 <br />(Pf54az.Z.1 <br />Section <br />WORK TO BE PERFORMED: <br />ANEW WELL! BORING ( <br />*Other: <br />COMMENTS <br />.,•'.1,...lros-AHENT HEAL1 <br />S'FRVICF <br />03 DEC 38 PM 3:46 W • 6,10 <br />C-57 Contractor 5 <br />Consultant / Sub Cntr <br />GIS Coordinates: X ,Y , Township Range <br />GEOPROBE, HYDOOPUNCH, HAND-AUGER OTHER*) <br />OIL BORING # P-vp iLyA 010. a WELL # <br />ri DESTRUCTION (choose type below) <br />a OVER-BORE <br />Grout Specifications: `Pei/4ND <br />yESSURE GROUT <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />MONITORING 1:1 HOLLOW STEM <br /> <br />EXTRACTION I] AIR HAMMER/DRIVEN <br />I] VAPOR <br />U MUD ROTARY <br />U AIR SPARGE / OzOrteXPUSH POINT <br /> <br />)(SOIL BORING HAND AUGER <br />U OTHER: ri OTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE Z" MULTIPLE CASINGS? MULTI-LEVEL? WELL CASING DIA:v <br />CASING THICKNESS A/M- TYPE OF CASING: j] STEEL PVC OTHER: N <br />DEPTH OF GROUT SEAL 51 1 TREMIE TYPE TO BE USED: el AUGERS AROSE <br />GROUT SEAL PUMPED: a YAs No (NOTE: MAXIMUM FREE-FALL DEPTH 30') g <br />GROUT SPECIFICATIONS: -Pot r 109,0 TpL 1L_- <br />APPROX. BORING DEPTH 50' fl BOLTED TRAFFIC BOX or STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />iA) GA( P/fir\; dciti,pv,v)) Dsh-To (Dc4-0,19c zoo.) <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 />Signed x <br />Print Name <br />WORK PLAN DATED: <br />Application Accepted By Date Issued <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDMONS: <br />ACCOUNTING ONLY: AID# <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY INVOICE DATE - MIT/SERVICE RE. 6 --. 6 4444 <br />"o/ - ff.- / yizer ,;‘,4-- 1- __ _5. xlve .5b 5742 <br />"14) DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 6c7:02-7 /(7, ety)e)e7dee <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 Re ulations, and all applicable California tate Laws. eup <br />_.......) <br /> Title/Company A 0 ..XC <br />17— J C uci14." Date 0 • Y <br />Date <br />Date <br />Final Inspection By <br /> eaY <br />Area Date #4? 1°9 <br />C-57 17 WC AXWAIVER Encroa 8/29/02 C-57 Letter of Authorization to sign permit