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WELLPERMIT APPLI <br /> 3 FILE Y <br /> � CATION FO'FtM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ck ATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT A <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 ON <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 /> WELL Locationr�l'm E_ Fraly► o 5T be Cross Street fi I T Si'. <br /> _ Ci ry SToklrn ipYSdDS Assessors <br /> Parcel# /S <br /> 3'•? S-F8k8 <br /> PROPERTY Owner Addressp0•BOX7$0 6 _Uo <br /> (5 <br /> C-57ContredorZtilll�Addressg5Ohoe A4 Ciry hWZ Zip9yfYLic# Phone#P5-d/d- <br /> Consultant/Sub Cntr�M4b�IQE1lV1i'Orlll"aLtl4lAddresso27oPerk)ns Sy- CityS_kALAi�Uc# Phone#762-W oUi0 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: _ <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> ;SOIL BORING#��SB'I3, 58'/� SB-IS a OVER-BORE. DIAMETER <br /> HWELL#S'3-E5. SN-S$ Y� OPRESSURE GROUT <br /> a*Other —f GROUT SPECIFICATIONS <br /> COMMENTS: _ dial /y <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )(MONITORING HOLLOW STEM DIA.OF BOREHOL •O MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS Y0 TYPE OF CASING: p STEEL JfPVC O OTHER: <br /> 0 VAPOR NMUD ROTARY DEPTH OF GROUT SEAL 70' TREMIE TYPE TO BE USED: D AUGERS XHOSE <br /> H AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: '(Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS 7 6-em&T <br /> H OTHER: R OTHER APPROX.BORING DEPTI Ijj IddK�IOO bOfr BOLTED TRAFFIC BOX or a STOVE PIPE <br /> ' CONDUCTOR CASING PROPOSED(if YES,list specifications in comment section) <br /> COMMENTS: S�I—$S tbiloo-e Ths-Nit r11� t�Ji`t% aCau UCjZwr CNOA5 AotoNTo ^' 70�I�eaTbc[ow�Natfd.., <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. T <br /> Signed x � `' —Adxx� 04 (� v1.p __Title/Company <br /> Print Name 1 , f )1�1 1 t vP r ('hi r 1 C r Date 10 <br /> DF-P�A/RTMENT� ,,� / <br /> USE <br /> �ONLY a <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Zr` T f ��"�o 0 &0 <br /> WORK PLAN DATED: 0 2_ ZO •02� <br /> Application Accepted By Date Issued -40 Z Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3501 _ �S io_Z sR# (0031Po9 <br /> C-57 WC /-WAIVER— C-57 Letter of Authorization to sign permitvl�_Encroachment doc 9/30/02 <br /> �Tn�.usCe.( <br />