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F11 F Y <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> 1 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> l / 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 O/�r <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 aN the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location // Ff 57 /N Cross Street Fr JDCa Sr. CiryTpckttan 5Zip d Drj Parcel# /'/1-17LIO-AA <br /> PROPERTY Owneer(1ty 0City S klW Zip9�Phone#aut'137.56 33 <br /> C-57Contractor6:!Mq 1YjSZtLk AddresSM AIW-G Rol Ciry rti YV. 2ZiplLio C56Ho)Phone#Y�?S-3l3-S (Z <br /> aT <br /> Consultant/Sub Cntrl'anabri4Env Address a715?eykinS 6r. Ciry, onax Lic# Phone#7o7-933•d369 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: _ <br /> O NEW WELL/BORING CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) D DESTRUCTION (choose type below) <br /> KSOIL BORING# -Q. 68-I5 DOVER-BORE. DIAMETER <br /> D WELL# D PRESSURE GROUT <br /> D'OtherGROUT SPECIFICATIONS <br /> COMMENTS:'!R �aI n n IYn Y-?At 6 Tol2Wallk./[J 6tA 6� {Ye.WtM? 5T OA tftj Q"ey)V <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING D HOLLOW STEM DIA.OF BOREHOLE c2_' D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS N 14 TYPE OF CASING: D STEEL D PVC D OTHER: <br /> []VAPOR D MUD ROTARY DEPTH OF GROUT SEAL 1&0' TREMIE TYPE TO BE USED: D AU gggparm <br /> D AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: XYes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> $SOIL BORING D HAND AUGER GROUT SPECIFICATIONS e0 QdAtq YUfit r <br /> D OTHER: D OTHER APPROX.BORING DEPTH 190' u []BOLTED TRAFFIC BOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED Al d (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinanc , les egulations, and all applicable California State Laws. <br /> Signed x } � Title/Company Y7`11 n J-r <br /> Print Name Ch Y, prooe r Date <br /> DEPARTMENT USE ONLY 1 <br /> SITE MAP IN UNIT IV FILE, ADDRESS: "2#7'/ e' lrta ' �i <br /> WORK PLAN DATED: t6'Z0'O Z' <br /> Application Accepted By Date Issued �L r Area a 0 <br /> Grout Inspection By Date Final Inspection By ate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE BODES FEE INFO AMOUNT REMfTTEDj CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST If INVOICE <br /> .35o1 813 89 /$S17 /o-7 SR# <br /> C-57WC=WAIVER_ C-57 Letter of Authorization jo sign permit ✓Encroachment doc_ 9/30/02 <br />