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WELL ,3ERMIT APPLICATION R. Zm <br /> SITE <br /> i SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton , CA. , 95202 <br /> (209) 468-3449 p � t <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FILE Y <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 San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> - I / / /' ___ Assessors <br /> WELL Location Z.J75 �6rn '�-iy � �G..h Xlv� Cross Street � �y"tfx K,WCity STv c/� a^ Zip Parcel# <br /> PROPER? £ 1c rPs LLC' 6vo I!U <br /> Owner! Address 1990 oos l 6kLA51t4s" City c4o�.,s�^ r'X Zip 77a 4Phone# <br /> y < —/ T, /-ie 6�e...-i'a.. �,y �'l"^.7 C CS7 <br /> C-57 Contractor/ ;e �u �':/�• ^9 '}7 13AddressrI SO Efoi..e f}vcnr o City ' fPZip9YS Lic# YPS<65 Phone# 925- 3/3^586a <br /> Consultant ra � ^f"^" Addle sin Ger �,;.sS><rcew< City .�'vn•4 Lic# Phone# 7o7- 933 -L369 <br /> GIS Coordinates: X., Y , Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL / BORING (CPT, O ROB HYDROPUNCH, HPNqp-AUGER, OTHER') p DESTRUCTION (choose type below) <br /> PKSOILBORING # :56w ] t4.r L 6- / Y «' �F "" C / DOVER-BORE. DIAMETER <br /> WELL # M LV15 O PRESSURE GROUT <br /> 0 .Other - - - GROUT SPECIFICATIONS <br /> COMMENTS: <br /> µTYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS GJ <br /> MONITORING /Id�HOLLOW STEM DIA. OF BOREHOLE 10 " 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: y <br /> 0 EXTRACTION D AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL )' PVC [] OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL y TREMIE TYPE TO BE USED: [] AUGERS 0 HOSE <br /> 0 AIR SPARGE/ OZONEPUSH POINT (GP or CPT) GROUT SEAL PUMPED: 0 Yews /YNo (NOTE : MAXIMUM FREE-FALL DEPTH IS 30) <br /> 1 I <br /> SOIL BORING AND AUGER GROUT SPECIFICATIONS /iCc,...r�ws/r oi. Be.-'2�.a�-S�<✓i <br /> 0 OTHER: N OTHER APPROX. BORING DEPTH ZO_ BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> / CONDUCTOR CASING PROPOSED_ /-�rD (if YES, list specifications in comment section) <br /> COMMENTS: So . � � - � T?p <br /> NOTE : OFFSIT ORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances u a g lations, and all applicable Califomia State Laws. <br /> Signed x Title/Company �lO <br /> O <br /> Print Name l �y�l�� Date G <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : ZSR 600 �). Cw6 P5Lud — LOP <br /> WORK PLAN DATED: 5 -z $ -a <br /> Application Accepted By Date Issued 77 ' 04 Are 84- <br /> Grout Inspection By. Date Final Inspection By -' 't.( ' 3 -d (i —Z ate <br /> Destruction Inspection By Dale <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT I SERVICE REQUEST # INVOICE <br /> .t/ M� S4 � /?e 7- a* 60 � SR# 0 <br /> C-57_nit WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc /# 9/30/02 <br />