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WELL PERMIT APPUCATION FO A SITE <br />� �� <br />to C tires � <br />" ( SAN JOAQUIN COUNTY f Nlli"IGATlON <br />'c� UNIT IV <br />ENVIRONMENTAL HEALTH DEPARTME+ T (&D) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />, _IP. 9,,,d ' a (209) 468-3449 <br />v vx VZ(,NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />Applicaficn is hereby made to San Joaquin County for a permit to construct and/or install the work desc abed. 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 />WELL Location lO� w. C � C' s i — --- --- Assessors -- <br />Cross Street �a�r� City hoc Kion Zp Sa0(o Parcel# <br />PROPERTY Cwner� SS ((Cor& rtJ,4,-on Address %3Q w. C �� Sf City S-foc,�fon Zip %So)C3b Phone# 9�1r�- D 30Z <br />C-57 Contractor Cascade. Address 363-L 0Mec. C;rc IC C;ty"'Lhy _Lip 9.57y1Lic# 717,5/(o Phone#1(03_8- I1(,'I <br />Consultant/ Sub Cntr ArXUGnC eb__ GI -0 Address .J City S� �' _Lic1 _ _Phone? yin? <br />GIS Coordinates: X -__ - _, Y _ , Township RangeSecticn <br />WORK TO BE PERFORMED: <br />p NEW ViEt1 / BORING (C, -T, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) DESTRUCTION (choose type below) <br />0 SOIL BORING #i _. C.OVER-BORE <br />r 0 WELL # 0 PRESSURE GROUT <br />`Other: _S L-) — 1 — — - -- --- ---Grout Specifications: \�eA +On -�C_5---- <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />I MONITCRING Q HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 MULTI-LEVEL? fj WELL CASING CIA: -- <br />0 <br />A:_0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS _ TYPE CF CASING: I] STEEL PVC O OTHER: -9 <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL,=a TREMIE TYPE TO BE USED: 0 AUGERS ;10SE <br />17 AIR SPARGE / Ozone 0 PUSH POINT GROUT SEAL PUMPED: o Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH 15 30') <br />0 SCIL BORING 0 HAND AUGER GROUT SPEC!RCATIONS: <br />7 OTHER:. OTHER APPROX. BORING DEPTH S& 8 BOLTED TRAFRC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? _ (iff YES, list specifications her(,):____ _7I <br />`COMMENTS 761)P 3 O F boo i 1\ \ /�be- Nak--Ve <br />t .l I I _—Sl�O�I� �C7 hc�TlO+ti� O ?rgeo sclj Otter e- CCG.yc.T Old --- <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS 1N ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />hereby cartify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />�ounty Ordlj�a es, Rules and Regulations, and all applicable California State Laws. <br />Signed x do—`I%%C —per Title/Company-4 1 U� A (e — <br />,int Name.—_C Yic �3 �ppher t`-. , ¢r ---Date- <br />t DEPARTMENT USE ONLY <br />`ti /�-- <br />51TE MAP IN UNIT IV FILE, ADDRESS- /A„ (91��'„ „ A—.4 <br />WORK PLAN DATED: <br />\pptication Accepted By_ <br />gout Inspectlon By <br />)estruction Inspection B, <br />-OMMENTS I CONDITIONS: <br />(IV— <br />Date <br />(IV - <br />Date Issued <br />nal Inspection By IDate <br />MMMEWTEWWAVAM <br />ACCOUNTING ONLY: <br />AID# i1a r C t1S <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D 9Y <br />I DA <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />15s �? <br />.®O <br />2— <br />-57 WC -WAIVER C-57 Letter of Authorization t siq� permit Ener -en dam— 8/29/02 <br />