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FILE COPY <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> w � ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> f 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 Df Cbs <br /> U NON-REFUNDABLE PERMIT EXPIRES-1 YEAR FROM DATE ISSUED <br /> Application is hereby made t4rRan qmn County for a permit to construct and/or install the work described. This application is made In compliance with San Joaquin County <br /> Development Title, "`--'-' ^ " ' ^ ,n^ Standards of San Joaquin County EnvirBnmental Health Department <br /> SVMMI'I- /1D Assessors <br /> WELL Location Z �� _Cross Street f. je4l., Lity 'ST )(Tr>r Zip ci 5 z�7 Farrel# <br /> PROPERTY Owner,.yC i ` # F ro Kr n Address 345 A1 , EL J`RAOT City, 57o�ct�frroo .1 zip95�Zo Z.Phone# 2a9 995 ' ;l r/ <br /> C-57 Contractor, _ , ddress� Ciw —'iw�ri`Ic�hone_ �7 L �S/Q <br /> Consultant / Sub Contractor 4 , 6 ,r Address L5 S 4� RD ry <br /> Civt� YT LjLic# bflotz7Phone# 2oG ^ Y67 • / ae 14 <br /> GIS Coordinates: X Y ,.Township O1 nt Range 1 � Section J <br /> WORK TO BE PERFORMED: <br /> `ANEW WELL I BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br /> (Q 0 DESTRUCTION (choose type below) <br /> p SOIL BORING # a OVER-BORE <br /> ^SWELL # MW '7 ? o �7'` aPRESSURE GROUT <br /> 'Other: 7 Gmut Specifications: rnr7 O lie, <br /> COMMENTS: Sa4E AQyrrt��eD woRK Plan Q- t-zO IS FF pipyA . -1 2so 'L <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'MONITORING 'HOLLOW STEM DIA, OF BOREHOLE Str MULTIPLE CASINGS? BYES fiV0 WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS ( TYPE OF CASING: Q STEEL PVC 0 OTHER: <br /> O VAPOR p MUD ROTARY DEPTH OF GROUT SEAL4e Fp 05 r THEME TYPE TO BE USED: AUGERS 0 HOSE <br /> a AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: p Yes Y& (NOTE: MA�rXIIMUM FREE-FALL DEPTH IS 30') <br /> C SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS; f ti r d4 Ty r <br /> o OTHER: R OTHER APPROX. BORING DEPTH 95 FT f35t BOLTED TRAFFIC BOX or O STOVE PIPE <br /> / C ADUsCTOR CASING PROPOSED? Niel ( if YES, list specifications here): <br /> *COMMENTS: � D <br /> X&OIZ D� Suat 44. e7- <br /> NOTE: OFFSITE BORINGS ROQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REdUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> Rules and Regulations, and all applicable California State Laws, <br /> Signed u t TitlelCompany ' @C T P tl C , / <br /> Print Name UrLLgA, Date (J5 Z <br /> �j DEPARTMENT USE ONLYif <br /> SITE MAP IN UNIT IV FILE, ADDRESS : #0/ ate <br /> `- <br /> WORK PLAN DATED : -- IS ' 2✓ <br /> Application Accepted By Date IssuedAB ":Grout Inspection By DateFinal Inspec <br /> Destruction Inspection By Da <br /> COMMENTS / CONDITIONS: <br /> /O <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # RECO BY DATE PERMIT I SERVICE REQUEST # INVOICE <br /> �5o 91 /68' 's / SR# 06 0 9 <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permi _ Encroachment doocc_ 1/25/02 <br />