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WELL c.' RNMIT APPLICATION FL . . M SITE <br />' SAN JOAQUIN COUNTY MITIGATIONUNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton , CA. , 95202 <br /> (209) 468-3449 <br /> I <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 /> . 1 `` ii 1� Assessor' <br /> WELL Location 71 N Ttl7 tJ� 1:' Cross S/t�reet �- City S Ii�Gtk' 1�� /A�J.Z'Ip ^2 �2 Parcel# r' <br /> PROPERTY Owner DCtl n ;S FIZGYG1I Address Po RD City$> ��Zip RQ 4'Phone# <br /> C-57 ContractorV ii IH nCAddres-5i� —! 2(�`t�,( Vrc k City ` <br /> Consultant / Sub Cntr U Address V J�IGry J=e City. kkt ) Uc# (��1�27 Phone# a 4/67/AOb <br /> GIS Coordinates: X Y., Township Range Section <br /> WORK TO BE PERFORMED: - - <br /> ( QEWI ELL BORING ( CPT, GEOPROBE, HYDROPUNCH; HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br /> D SOIL BORING # D OVER-BORE <br /> WELL # l�Ll1tJ - 0 PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> tKMONITORING 'HOLLOW STEM DIA" OF BOREHOLE AFl/1/ MULTIPLE CASINGS? 11 MULTI-LEVEL? ' WELL CASING DIA: 2 � <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS e4h TYPE OF CASING: fl STEEL JtPVC Q OTHER: <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL IS TREMIE TYPE TO BE USED: XAUGERS 0 HOSE <br /> D AIR SPARGE / Ozone 0 PUSH POINT GROUT SEAL PUMPED: D Yes J;rTlo (NOTE: M94 7V <br /> DEPTH IS 303) <br /> :! <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONSDry/a H d f;4! .c..�E /4 7Vt 7�:3 fo�^AL N� D <br /> D OTHER: fl OTHER APPROX, BORING DEPTH 4o ✓ BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br /> *COMMENTSMi)yr( � is <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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, Rules and Regulations, and all applicable California State Laws. <br /> Signed x� 4lrr r�-�C� O f Title/Company �-[�I S D� Yc <br /> Print Name �Q 'Vl I t? I � 4'i. l WL Loa CV \ Date D <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: l , <br /> WORK PLAN DATED' <br /> Application Accepted By ✓ Date Issued Jcw 2L?,+ F04 Area <br /> Grout Inspection By Date Final Inspection By Date - <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS, <br /> ACCOUNTING ONLY: AID# - <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT ! SERVICE REQUEST # INVOICE <br /> 350 9 . DC) Lp z Vz _&iS R 3S <br /> C-57_ WC -WAIVER_ C-57 Letter of AuthiWiz io sign permit_ Encroachment doc_ 8/29/02 <br />