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IU/Oti/ZbbZ 10: 41 Y0'd4bB3433 FIFTH FLOOR PAGE 04 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appllcadon is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made in Compliance with San <br /> Joaquin County Development Title,Chapter 9-9115.3 and the Standards of San Joaquin County Environmental Health Department <br /> Assessors <br /> WELL Location I B S, Sac✓u.,,¢'n/ f0 S/, Cross Sheet IA-"A'A Or-, City �d�i 7jp /5'�T Parcel# ()�k.--3'94 2 - <br /> PROPERTYOwnerIefAld, T. yi,.c{Pr l+„S Addrreess ,�r/rn•n tnt.�t City d�r Zip�GPhone4 <br /> C-57 Contractor �/-Y�^LJ }—,nri f/inr, Add(e /q <br /> ss /.J� hdwe ACity M'f,nezZip9Kjr3 Lic#� 0elPhone# 9zs11). 1S-5,fe& <br /> er <br /> Consultant/Sub Cntr / Address _. ��� 6..fr('IaICity A•ddr1t UC# Phone# OD <br /> GIS Coordinates:X Y .Township Range Section <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) D DESTRUCTION (choose type below) <br /> P60IL(BORING# SB—Lf�- 0 OVERBORE. DIAMETER <br /> D WELL# D PRESSURE GROUT <br /> D*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS IV <br /> D MONITORING HOLLOW STEM DIA.OF BOREHOL 1n,D MULTIPLE CASINGS D MULTI-LEVEL W ELLCASING DIA: IVIA <br /> 0 EXTRACTION 0 AIR HAMMERlDRIVEN CASING THICKNESS__A!,4—__TYPE OF CASING: 0 STEEL ]]PVC n OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL 7D ft, TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> G AIR SPARGE/OZONE G PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ; Yes n No (N- OTE: MAXIMUM FRE&FALL DEPTH IS 301) <br /> SOIL BORING G HAND AUGER GROUT SPECIFICATIONS IV$Ar} C?eM e n r <br /> G OTHER: 0 OTHER APPROX.BORING DEPTH 7D 41-, G BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED /4 ,9 (it 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 Ordina�ncfuiations,and all applicable California State Laws, <br /> Signed 77 <br /> Tile/Company P/2oJkmsI PZI�r O Uc1L <br /> r►� <br /> PrinlName O r Dale <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 7p 7 <br /> 4ppiication Accepted By ' U Date Issuedd��l Area <br /> 3routlnspaction Bye_ Date 0107 Final Inspection By Date <br /> Destruction Inspection By Date <br /> ;OMMENTS f CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CEDES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT f SERVICE REQUEST# INVOICE <br /> J� Y SR# pd3Z-2 7 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/30/02 <br />