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E' , <br /> WELL ERMIT APPLICATION FIsAM <br /> SITE <br /> - C 1J I�_. SAN JOAQUIN COUNTY <br /> I' MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 8 7005304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> EP�'M ,�i[W`Ci NT IJrAL7 i {209) 468-3449 <br /> I'EIIrAT/SERVICFS NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATEISSUED <br /> Application is hereby made to San Jcaquin County for a permit to construct andlor install the work described.JNS 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 /> r, woad D,,v� I Assessor's <br /> WELL Location 5151 Al-,,6 <br /> Cross Street Olegh�rer city M�an1-e�� zip 85337 Parcel# 2y3 -q30- 13 <br /> IPRCPERTYOwner rr:s Address 5151 /4l—o-dwodd Dr.CityIM4Rkc0\ Zip 15331 Phone# -Loq- -2 3,y- 1361 <br /> C-57Ccntractor 1"%ScL, FAvt«^n^e„61Address 3904 5[,,e,r;,I Place I� <br /> CrtyVarre� Sp/:,�ip X52MLic#f6fi'J8b5 Phone# aoq-77z-3S 76 <br /> Consultant I Sub Contractor Address 1114 Ma:., S+. Ciiy Escc,';lo.. LichPhoneK u <br /> ?a9-✓�3&'988$ <br /> G15 Coordinates:XY Township S Range 7 E Section I el F <br /> WORK TO BE PERFORMED: <br /> ,NEW WELL PBORING(CPT,GE'OPROBE,HYDROPUNCH,HAND-AUGER,CTHER') QDESTRUCTION(choose type te!ow) <br /> R SOIL BORING# C-Vr?, !I D OVER-BOF,= <br /> SWELL. Mwg w9 wlo ,Nwit I d PRESSURE GRCUT <br /> '^ether: Grcut Specifications: . <br /> COMMENTS: <br /> it <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS !i <br /> RMONITORJNG ------>ja HOLLOW STEM DIA.OF BOREHOLE 9S" 2"MULTIPLE CASINGSS?U YES ONO WELL CASING DIA: 2 <br /> ' C EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS t,ck. 4 c TYPE OF CASING: 0 STEEL ;D PVC <br /> ()OTHER: <br /> D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL z,S F1•. 2 b F.7jREMIE TYPE TO BE USED: ff AUGERS Q HOSE <br /> C AIR S?ARGE �APUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 37') <br /> �SOILBORING j]HAND AUGER GROUT SPECEFICATIONS: I-� ,-,A- ove.r 100.."}a 1-t <br /> 1]OTHER: D OTHER APPROX.BORING DEPTH �`1Ff? �� �t!l� BOLTED TRAFFIC BOX or O STOVE PirE <br /> I CONDUCTOR CASING PROPOSED? (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 FQR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will beldone'in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Sicned x Title.!Company ;l [ 5� C- KX-4 aev) At S� <br /> F- 4;ntName AA V_l I Date_ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Gt,( � I� UPI- <br /> 1010RK <br /> PLAN DATED: ► r II <br /> � 7 <br /> Arplication Accepted By •1 Date Issued If o Area b-1_ <br /> G:--L:t lnspecJon By__ 1�� _Date Final lnspection"By_ (A[i , Date <br /> C=__z:-uC,icn lr,sce_t;on By Date <br /> :'C:'.',IENiT;.!CONDITIONS: <br /> ACCOUNTING ONLY: AlD# I i <br /> cclu2s FEE INFO AMOUNT REMITTED CHECK# RECZ BY DATE � PERM iIT I SERVICE REQUEST# INVOICE <br /> SR <br /> L:-57_ '�'.,___-WAIVER C-57 Letter of Authorisation to sign permiti Encroachment• doc l/25/02 <br /> ll . <br />