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WELL,., RMIT APPLICATION FG,.�+A SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 of tp'j~-' <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 9-111r5.3and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location�r+40 E �c-Crno-t7 Cross Street F� s" <br /> City ���"Ic�t Zip 2.as Parcell! <br /> PROPERTY e <br /> Owner-T__-� ,_ o�X AddressG!5 Z3 So F ..ola C,�CiIyS•��� ZP qs Z- .phone# /� Tl <br /> :I <br /> / 00 <br /> C-57 Contractor�r oc .,< . Address 5C /7 at-ue Q.on Ci ntZ Zi Lic#6 Phone# Z-5-3�3- <br /> Consultant/Sub Cnlr '--41J' AddressZ-- k,ed :54. City75L + +.c Lic#RG �'Z- Phone# �o�-S35-L/8S0 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,NAND-AUGER,OTHER') O OVER I] ESTRE.UCTON <br /> (c oose type below) <br /> SOIL BORING# -S 3-Z O PRESSURE GROUT <br /> p WELL#•Other, GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 3 ' a MUU,LTIPLE CASINGS [I MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS N(" ' TYPE OF CASING: 1]STEEL 11 PVC 0 OTHER: <br /> U VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL I So ' TREMIE TYPE TO BE USED: I]AUGERS ;Q HOSE <br /> AIR SPARGE/OZONEXPUSH POINT(GP or CPT)GROUT SEAL PUMPED: XYes a No (NOTE: MAXIMUM/ FREE-FALL DEPTH IS 30') <br /> �`-4 <br /> SOIL BORING 1]HAND AUGER GROUT SPECIFICATIONS 410( CA.Mt^'r !"1-7 <br /> Q OTHER: N OTHER APPROX.BORING DEPTH 15a / O BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED— //A(if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE B RINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules <br /> �and <br /> �lRegulations, and all applicable California State/Laws. f <br /> Signed x_____- �� /�/ _ Title/Company Sa. r <br /> Print Name Ge ' v CT"�Tr'�: ^ ' Date <br /> DEPARTMENT USE ONLY it <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued t0 Area�(O <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMfTTEDjCHECKa# REC'DBYDATE PERMIT/SERVICE REQUEST# INVOICE <br /> SB $9� b-1 ,-,+ SR# 66.3- <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />