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r� <br /> WEL%wPERMIT APPLICATION F eiRM SITE <br /> IIAI 7fI SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 02 FED 19 01 900f• Weber, Third Floor, Stockton, CA., 9520 <br /> (209) 468-3449 ` <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 /> WELL Location 2-&61 •nowt/. ,r Assessor's <br /> A orf We Cross Street fcsf /L city City StofJC'Eon Zip Parcel# A.' g — /ZD-O 2 <br /> PROPERTY Ownerara �ee- l� A'e< 63toS- <br /> S w G'ro,.� Address�400Mary�cnd Cityst•LoM.�S Zip346$ Phone#�314)254-7073 <br /> i <br /> C-57 Contractor Syectew.w Address 236 5 Q! w R CitySf c tnn Zip 9520$ Lic# Phone#&o9 5- 3 7 t Z- <br /> Z Scud baw�C <br /> Consultant/Sub w�S'E <br /> Contractor !o Ir I�*P 5&rarcas Address Cit, (02-7-34 Lic# Phone# &IF)Z VI- 1547 <br /> D t <br /> GIS Coordinates:X .37 D 55 N Y I Z I 15 w Township 7- //`1 Range R9 E Section 2- 2- <br /> WORK <br /> - 2- <br /> WORK TO BE PERFORMED: <br /> )ZNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) a DESTRUCTION(choose type below) <br /> 0 SOIL BORING# OVER-BORE <br /> ,WELL# P - PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING HOLLOW STEM DIA.OF BOREHOLE I.25 MULTIPLE CASINGS?n YES XNO WELL CASING DIA: 3/f- <br /> a <br /> � <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: n STEEL XPVC a OTHER: <br /> p VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 5$ ' TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br /> XAIR SPARGE a PUSH POINT GROUT SEAL PUMPED: XYes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: C'o <br /> a OTHER:_0 OTHER APPROX. BORING DEPTH G 5 b BOLTED TRAFFIC BOX orgy STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?_LLO (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 and Re uI tions, and all applicable California State Laws.` <br /> Signed x /' "L�/1,24 <br /> / Title/Company PA r �r (� X-✓J t C e $r <br /> Print Name P741.)< yv//1,24.1 N Date Z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2:6 rZ <br /> WORK PLAN DATED: Z ,!4OL <br /> Application Accepted By Date Issued 3�/L Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT R ITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> a 1 y?82- ®�3 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permits Encroachment doc_ 1/25/02 <br />