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0 FILE CU <br /> • <br /> WELL PERMIT AP PLIOATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> E � 304 E. Weber, Third Floor, Stockton, CA., 95202 <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 Dee�pa��jjrtment•Assessor 7J ( n/D O <br /> ��� Cross Str \ Or. City�� c Zip C—Parcel# l'3/'U <br /> WELL Location -A <br /> Ci (1� .�.�, tJE_–ZiP(ogio2 Phone#(L02 `191- oDO <br /> PROPERTY Owner kA2-E L Address 1�� v�tn. --r— <br /> Rh5S3 <br /> Address9so Tt�?w< 211 CityMo�rk.�� Zips—Lic#��51�5 Phone#{`1ZS�313-5Ro0 <br /> C-57 Contractor Cr�c�,��s;1 C�.�� — <br /> L F-1 Ci 0 Lic# Phone#�51o�(elr�-4100 <br /> Consultant/Sub Cntr;rc �tr,�Ca� ,.Address 2101 5� �— — <br /> GIS Coordinates:X ,Y <br /> Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION (choose type below) <br /> ;ANEW WELL/ BORING (CPT, RO HYDROPUNCH,HAND-AUGER,OTHER*) []OVER-BORE. DIAMETER <br /> 'SOIL BORING# Z LGnAx-IS d 0 PRESSURE GROUT <br /> G WELL# GROUT SPECIFICATIONS <br /> 0*Other <br /> COMMENTS: s <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING []HOLLOW STEM DIA.OF BOREHOLEI,,-,! 0 MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA:N� <br /> 0 EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS t/A TYPE OF CASING: 0 STEEL 0 PVC []OTHER: �JA — <br /> H VAPOR []MUD ROTARY DEPTH OF GROUT SEAL T}G Q _TREMIE TYPE TO BE USED: Q AUGERS _WHOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes G No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> `.SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS BOLTED TRAFFIC BOX or �STOVE PIPE <br /> OTHER: []OTHER APPROX.BORING DEPTH 2-0 � � _D <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 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 Ordinancles�Rules and Regulations, and all applicable California+ State Laws. <br /> Signed x Title/Company <br /> GT-11�C- � /C <br /> Print Name �x� C't���✓ Date g 121 103 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: �O <br /> Date Issued <br /> —241— � Area 06 �� <br /> Application Accepted By Date <br /> Date Final Inspection By <br /> Grout Inspection By f <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> *AUNTINGCON LY: AID# FAC# <br /> FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICD�T# INVOICE <br /> �911 //o0 3 2� ' SR#-WAIVER C-57 Letter of Authorization to sign permit Encroachment�� 9/30/02 <br /> W <br />