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WELL P&MIT APPLICATION FOR* SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT EH d lti `d}�EP )II <br /> 304 E. Weber, Third Floor, Stockton, CA., 52U � <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE 1 �F93 AUG —7 PM 4: 41 <br /> Application is hereby made to San Joaquin County for a permd to construct and/or install the work described. This application is made In compliance with San <br /> Joaquin County Development Tithe,,Chapters 9-111115.3 and the Standards of San Joaquin County Environmental Health Department, <br /> WELL Location G� i /f/A e•�- L K/ Cross Street fi x"-,;F 7`aN �o c:xToN 52.6. Assessors O O- <br /> City Zip` Parcel# /45 3 /d <br /> PROPERTY <br /> Owner 'S FPP L, Address f/00 v"AJI C-o­-77Fy City219^ t Zip32863phone# - y4- 366-48; <br /> C-57 Contractor kCIA7"CR MAR K Address 1'26 - 4-- /:c,•+3l✓cK�' Cif � � � `,'S7"76 X3326 <br /> Y Zip Lic# Phone (jCX7�[('ltg-� ¢• <br /> Consultant/Sub Cntr LFtZ LF✓�...� �kx� -t036 Cn1'7 <br /> 1'r <br /> Address City. L�UcG <br /> GIS Coordinates;X ,Y Township Range Section <br /> WOHI(TOB- ERFORMED: <br /> EW WELL 1 BORING (CPT,GEOPROSE,HYOROPUNCH.HAND-AUGER,OTHER-) U DESTRUCTION (choose type below) <br /> U SOIL BORING# U OVER-BORE. DIAMETER <br /> D-VVELL ZP A- —X> 5SP Pr-/O 11 PRESSURE GROUT <br /> a"Othor GROUT SPECIFICATIONS <br /> COMMENTS: 5'J+ac..✓.s� 4eti� 6Ra.�w,�J-�T'- rnn„To,2y,-� t.-a:GL <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING *OLLOW STEM DIA, OF BOREHOLE 6 " U MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: <br /> a EXTRAC71ON U AIR HAMMER/DRIVEN CASING THICKNESS Sc;/ '0 TYPE OF CASING: U STEEL )(PVC a OTHER: <br /> p VAPOR U MUD ROTARY DEPTH OF GROUT SEAL 5'7' S-f`rTREMIE TYPE TO BE USED: p AUGERS XHOSE <br /> a AIR SPARGE/OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED: XYes 13 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> U SOIL BORING U HAND AUGER GROUT SPECIFICATIONS /3c vTo /%_�_ C'n 3T' nYx <br /> U OTHER: f1 OTHER APPROX.BORING DEPTH zc>' U BOLTED TRAFFIC BOX or)(STOVE PIPE <br /> CONDUCTOR CASING PROPOSED .amu (if YES,list specifications In comment saetion) <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 Ordinances, Rules and Reulations, and all applicable California State Laws. <br /> .Sighedx <�—�--� - Title/Company Y"•a.zTi=c-7 - /tl.A.,..,.G.�=-j��i-i' LG-�•..•E 1=.�teKG <br /> Print Name Sc 7r- !4, /QFZM�T rdti� ! <br /> Date Orap <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 60A�� <br /> WORK PLAN DATED: _- <br /> Application Accepted B Data Issued 17 14, � Area <br /> 2/ <br /> 3rout Inspection By Date '$ 0 Fina Inspection By Date ,�- t7 2 <br /> Destruction Inspection By C11 Date <br /> ;OMMENTS/CONDITIONS, <br /> ACCOUNTING ONLY: AICs: FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> J. `d sR* y <br /> 57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />