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00R, 19. 2002012:49PM 2094f0i'K & ASSOCIATES FIFTH FLOOR NO. 5411 P. 2 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON RE NDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> Applimuon is hereby made to San Joaquin County for a permit to construct andlor install the work described, This application is made In compliance with San <br /> Joaquin county Development Tile,Chapter}11153 and the standards of San JoagyinCounty EnvlromrnsntalHealth Deparanent.Ass essor's 360'-3$ <br /> WELLLocatton 1531 W NVI&I Dr. <br /> Cross Street W.tSt Cla Q,{• }-at7 Zip 5205 Parceib I1`7 <br /> $an 5oar1 min Cal¢Ve.rrt5 Cn-.u,t-1 7 20S -honer. °1.PQ•�62. 6`75 <br /> Address I 3 j �^I Dr• Clry 'Ib..Gki'O;�ZiP.�� �I <br /> PROPERTY OwnerBka+.ica� ITS _L5_ <br /> —J"�'�" Rae d,o �5�(tj icx�l�s PhonetF 5Ib. b3$•T09 <br /> C-57 Contractor Ce�r odp.�Yi 1,(61 Address '+,4,'3'L r7mec G•rcl>~ Clry�-dcva zip �bo,9'{2,5147 <br /> 1�Lu12k � j`sscc-. Address (,05 iYird S —cla "� suds Pnanett <br /> ConsultanllSub CenvaUor <br /> GIS Coordinates:X ✓�x.59 r 0,,1 ,r Y I2•I D I(n `{fO If .Township Z l'J Range <br /> D� Section_7O <br /> WORN TO BE PERFORMED- DESTRUCTION(choose type below) <br /> �.NEWWELLIBORING(CPT,OEOPROBE,HYOROPUNCH,NAND,AUGER,OTHER-) DOVER-BORE <br /> U SOIL BORING x 8 PRESSURE GROUT <br /> 'VWELL 7r ISI— I n <br /> Grout Spedra <br /> fiUons <br /> -Other: ; <br /> COMMENTS: S ' <br /> TYPE OF WELL INSTALLATION TYPe CONSTRt1GT10NSPFCIPICATIONS �Jd <br /> IPLECASINGSII]YES UO WELL CASING DIA;y <br /> MONITORING WOLLOW STEM DIA.OP BOREHOLEJ.Qp_MULTTYPE OF CASING: STEEL �VC D OTHER: <br /> U EXTRACTION U AIR HAMMERIDRN6N CASING THICKNESS <br /> _TYPE <br /> VAPOR U MUD ROTARY DEPTH OF GROUT SEAL J-S TREMIE TYPE TO BE USED: GAUGERS )(Hose <br /> UAIRSPARGE [I PUSH POINT GROUT SEALPUMPED:`&Yes ONo (NOTE: MAXIMUM FREE-FALLDEPTHI 30r) <br /> U SOIL BORING U HAND AUGER APPROX.BOR NG DEPTH 17 O a OLTED TRAFFIC BOX or U STOVE PIPE <br /> 11 OTHER: n OTHER <br /> CONDUCTOR CASING PROPOSED' 1`-J0_(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 Regulation$,and all applicable Califomla State Laws. sSOL <br /> Titielcompany rb i eer <br /> Signed <br /> Dare• 3119 <br /> PrintName DEPARTMENT USE.ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> ApplicationyiKn *e-P a DL <br /> Datelseued <br /> Grout Insp Accepted BY Final Inspection <br /> OroutlnspectionBy Oate <br /> Dest uerren lesbeellon B Data <br /> COMMENTS/CON01710N5: <br /> M !(�Z <br /> ACCOUNTINGONLY; AID# cera <br /> PE CODES FEE INFO AMOUNTREMRTED CHECKS REC'DBT DATE PERMIT 1:1111:: INVOKE <br /> SR# Co2`?Jol <br /> C-57_ WC__-WAIVER C-57 Letter of Authorization to Sign permit_Encroachment doc_ <br /> 1/25/02 <br />