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WELL rERMIT APPLICATION F(.)r<M SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 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 Department. <br /> Assessor's <br /> WELLLocation 30 VtCTC)tZ RD • Cross Street(-L-UFF City LSD I Zip Parcel# 04'�-0S-'� <br /> PROPERTY Owner NO2 r1t CR u Addressr-/32 z PzGaL E nrSr4C'4­City S ZtKT*-j Zip_ Phone#(lq? _4 y1 <br /> C-57 Contractor V+w DfZ! L�rNro Address/OC) s� 5-T­1CitylStti:TOr`J Zip4S6q1 Lic# 0?0,1 Phone(91',)`r77-tf100 <br /> Consultant/Sub Contractor G�cc�.�D ZK RO / N�iN S na�cv� GAddressl7 `1 City Lic# X23 Phone# $3$ -985 <br /> GIS Coordinates:X Y Township Range Section <br /> W RK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> OIL BORING# 0 OVER-BORE <br /> ELL# M -► 9 R 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: SZ E.F1.a t m F_NT Fe)R M W q <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING XIOLLOW STEM DIA.OF BOREHOLE /0 " MULTIPLE CASINGS?0 YES XNO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sct'I-u?`fa TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> 0\/""OR 0 MUD ROTARY DEPTH OF GROUT SEAL 3 S r TREMIE TYPE TO BE USED: 0 AUGERS OSE <br /> 0 'ARGE 0 PUSH POINT GROUT SEAL PUMPED:XYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: /V�6i T GE i•C p�T <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH 6� �BOLTED TRAFFIC BOX or 0 STOVE FIFE <br /> CONDUCTOR CASING PROPOSED? .N 0 (if YES,list specifications here): <br /> 'COMMENTS: ���PCSt� GCJNS;12u ci'�On/ -O a—TJ LS 0Ek-T'7-i4C r*ED <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 aplRegul do , and all applicable California State Laws. <br /> Signed x Title/Company T- 6 rG23 G P-Gu.vD zCriz(Y A'v�``j sis <br /> Print Name G R 6 c tiY S i f} 14 L Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> cc -2� <br /> Application Accepted By v��\ Date IssuedT//% Area l? <br /> Grout Inspection B41 _Date/WdFinal Inspection By Date <br /> Destruction Inspectionkf Date 111Vdq <br /> COMMENTS/CONDITIONSLU: <br /> A. JNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ,ZR-or ?�--- �?� l 02- _ I-IV-- /z/ o 7 SR# <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ 1/25/02 <br />