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WELL ERMIT APPLIC <br /> ATION F�M <br /> ENV1R0 <br /> SAN JOgQUIN COUNTY SITE <br /> NMENTgLHEALT <br /> 304 E. Weber, Third Floor,H DEPARTMENT MITIGATIpN <br /> Stockton, Cq (EHD) UIN►? IV <br /> APplicatlon is hereby made to San Joaquin County fora (209) 468-3449 ' 95202 <br /> Joaquin'County p NON-REFUNDggLE PERMIT <br /> ty Develo ment Title, Chapter 9-t t 15.3 anpermit to EXPIRES RES 1 Y <br /> WELL Loc d the',,,a <br /> ct and/or install theAworROM DATE ISSUED <br /> Location f rds of San Joaquin described. <br /> , r,, , quin County Environmental his application Department.is made in <br /> PROPERTY Owner 0(,><7�p71J� /'�,� Cross street city <br /> S� Health Department. compliance with San <br /> Address 6o _ —Zip `/fhj Assessor's <br /> C•57 Contractor [ / T �Z Parcei-- <br /> St.. vi � .Sj�y _ Zip 7J=� <br /> Consultant/Sub On tr / Address �� City S _�„pp'!�! � hone# 0 7.4 71 <br /> Address L Zip Nl 4&#49'11'; <br /> GIS Coordinates:X Y 7Phone# C� 7_�L <br /> Ctry—�_Lic , L2 Phone# <br /> —.Township <br /> WORK TO BE PERFORMED —Range <br /> — <br /> UNEW WELL/BORING ;CPT GEOPROBF_!�ROPUNCH,HANDOT —Section� <br /> OTHER`) <br /> SOIL BORING#_$-/ <br /> 0 WELL# R� 0 DESTRUCTION(choose type below <br /> `Other: 0 OVER-BORE ) <br /> COMMENTS Grout Specifications: 0 PRESSURE GROUT <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE N <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEP CASING THICKNESS MULTIPLE CASINGS?0 MULTI-LEVEL?0 WELL CASING DIA: AIL <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: NA" <br /> 0 AIR SPARGE/Ozone PUSH POINT GROUT SEAL PUMPED: O E : TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 Yes 19 Vo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: /'ppa! <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH�Q / <br /> —0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? <br /> •COMMENTS: 4 �'S �DQ L^r07-O� � �C �ES list specifications here):-- <br /> NOTE: OFFSITE BORIS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOI WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have re ared It lication and that the work Will be done in accordance with San Joaquin <br /> County Or ces, es an egulisall applicable California State Laws. <br /> Signed Title/Company vvcr- 64-51,4&-p— <br /> Print Name <br /> DEPARTMENT USE ONLY Date 9 3a dL <br /> SITE MAP IN UNIT IV FILE, ADDRESS <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> Date Issued <br /> Grout Inspection By Date <br /> — _Final Inspection By Area <br /> Destruction Inspection By Date Date ------ <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMr.HECK# REC'D BY DATE <br /> PERMIT/SERVICE REQUEST# INVOICE <br /> C-57_ WC=WAIVER_ tier of Authorization to sign permit_Encroachment doc <br /> 8/29/02 <br />