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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> FILE (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 /> (� n ek 1 9�2 oL Assessors <br /> WELL Location ��SI JNCItk Hr'fPC rk Cross Street !L 5t�cf_f.CityU6f�C{r,.� Zip Parcel#_IQ41Z- 0037 <br /> i <br /> PROPERTYOwnerTk'tyc.ra+5 Go• Address PO 134(' 1$3o City$t,/..c KrS Zip 4311 Phone# i<i• Z54-7060 <br /> !{nd rev <br /> C-57 Contractor)n r'eq , .Sh 5;'L.+-- Address q50 go e- Rd. CityZipq+553Lic# Phone#(9zs) 313--5$00 <br /> YM c-a-04 <br /> Consultant/Sub Cntr Phil, $�'J Address ZiOLJsst $r.,dbu'TK City b%a Lic# ,Phone# �LiB)Z81- 15,+ 7 <br /> GIS Coordinates:X ,Y •Township 1 9`I Range 4 iE Section -L _ <br /> WORK TO BE PERFORMED, - <br /> I XNEW WELL/BORING (CPT EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") p DESTRUCTION (choose type below) <br /> a SOIL BORING# 7 0 OVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT <br /> i a*Other GROUT SPECIFICATIONS <br /> COMMENTS: "r ele. -7 CPT b r to 14Add✓a cej fir..- <br /> IIry TYPE OF WELL INSTALLATION TYPE .CONSTRUCTION SPECIFICATIONS <br /> ONITORING a HOLLOW STEM DIA.OF BOREHOLE_ a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> I ' a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC 0 OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS o HOSE <br /> a AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> {. 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> n OTHER: E OTHER APPROX.BORING DEPTH lOv a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: Cr llez* c� _f'4 :..�!'•k L•�"T rod S <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> I 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, <br /> Rules and Reg .I tion/s, and all applicable California State Laws. <br /> Signed / ✓rte J�-.r/ 114WCompany P41111•? th✓;�z.r M.c.,-�( i'✓tec �„-SJ. <br /> II i r_ <br /> Print Name /�i✓�C �i���.✓p Date__ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ;Z451 sau+k Air port <br /> WORK PLAN DATED: Eelo r u a r v -2 O z D 0 4 <br /> Application Accepted By 1 Or ; a LM c.Cq r e,u Date Issued J 0 rl e- 2 200 Area 1 45q <br /> Grout Inspection By`f•�A, i� � i Date (,. 11-2311-23/1 04 Final Inspection By Date L 10/6S— <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: AdyanefmealGPT. born s — -I - B`3 B- - - <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTEDIcHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3501 89.00 89.00 13 SR# QQ39 241 <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br /> _ <br />