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FILF <br /> �� SITE <br /> WELL PERMIT APPLICATION FORM YUP! <br /> SITE <br /> 3 rSAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 DN <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 /> SToc Assessors <br /> WELL Location aLK4 /E_ Erre,., wl- 5T Cross Street Fi Ib9rT 67 City4rcVA Zip Y5do5 Parcel# /S3'a8�'Og <br /> PROPERTY Owner�9!([A1�5�!/ Addreslss�F 0.80k- 186Q CityOH�YIk Zip SIO Phone# ^"flj06 <br /> C-57ContractorGYYM,�tilli q+zll Slt4 Ad dress�6-0#ptae R4 City IMPZ Zip7'9J^a Lic# S - Phone#9d5'd/d-3�foo <br /> 67 <br /> Consultant/Sub Cntr(4Wtbr'iQEhV'1f&W4Wp/Addressa70Pe7khtS 5t CityjLPA41140 Lic# Phone#7D)-f33^,?3G5' <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: _ <br /> p NEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER*) []DESTRUCTION (choose type below) <br /> XSOIL BORING#Sfl-1]y OVER-BORE. DIAMETER <br /> (WELL#S'3-85 SAN^SS n7-C� []PRESSURE GROUT <br /> [].Other --� f �(i/y —/ GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [MONITORING $HOLLOW STEM DIA.OF BOREHOL 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 40 TYPE OF CASING: 0 STEEL gPVC 0 OTHER: <br /> 0 VAPOR XMUD ROTARY DEPTH OF GROUT SEAL 70' TREMIE TYPE TO BE USED: 0 AUGERS XHOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: )(Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS t &*v"T <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTHWS &W)S1. BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED_yC$ (if YES,list specifications in comment section) <br /> COMMENTS: 1Ai11bP IYAS-tghQd WI A CLC"L4, Cy- C0.5INQ CAOU. TO -V 7'O'1 SOW$r4t(.(, <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 Ordi nce gulations,and all applicable California State Laws. <br /> Signedx r• ! },�Z Title/Company <br /> Print Name 1 S Ua -er Date -L� <br /> 7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: L ?� u � <br /> WORK PLAN DATED: o Z. d-Zo 2— <br /> Application <br /> Application Accepted By Date Issued ~ -� �' Areay <br /> Grout Inspection By Date Final Inspection By CO3tMffTEDate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: '�— <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTEDCHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ISR# et ileo 9 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br /> Mr-7aA AA <br />