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ORIGINAL <br /> e WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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 Joaquin County <br /> Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> /� QiFic, Ave , Assessors <br /> WELL Location �/c/ OS PAL rFrC.. AVt vte Cross Streetf talANchi 57. City Srot. KTon Zlpct52P7 Parcel# I ) O - -z43 - 14 <br /> f�c W <br /> PROPERTY Owner JE ftv CAC Tr n� �o Address4yes hkms6 'rq . Citysrcc Kron Zp Phone#(20rt) Y78 — S!5Q <br /> wes7erd ' W07 <br /> C-57 Contractor srn18 EsKr }fonAddressp. J . SItoi. � city � _ <br /> e#As � S <br /> Consultant / Sub Contractor A , 4 373 /1 fl <br /> G , F , Address837 SHAw� 154 CitySTK fa, uc#65CZZ7PhoneAK ? OV A 7� / Do b <br /> GIS Coordinates: X my , Township �i�7ref Range� Section <br /> WORK TO BE PERFORMED: <br /> EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br /> p SOIL BORING # 0 OVER-BORE <br /> 'Other: <br /> ELL # --Groutpecifcati .rte 0 PRESSURE GROUT <br /> r rS�D� TFcns: PCf % AND 7 �.YP !� <br /> COMMENTS: SG F e-D APPRn\rW hrK lor/ <br /> ./ D I S ARVII z on 2, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING `HOLLOW STEM DIA. OF BOREHOLE /O MULTIPLE CASINGS? n YES 4 fNO WELL CASING DIA: y <br /> O EXTRACTION PAIR HAMMERIDRIVEN CASING THICKNESS9'h� TYPE OF CASING: OSTE \L )kPVC aOTHER: <br /> X�VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALS FT 6SG TREMIE TYPE TO BE USED: AUGERS p HOSE <br /> 0 AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: u Yes ')KNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 3W) <br /> a SOIL BORING aHAND AUGER GROUT SPECIFICATIONS; Poril4il � 1YpC <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH 3 D FT 65(s XBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? N o ( if YES, list specifications here): <br /> 'COMMENTS: <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 I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> Rules an�dt Regulations,/and all applicable California State Laws. D /� <br /> Signed x /-r'MT�ncb�o. 1.1 . 1 yam/ '� Title/Company I_ C '/ �E o/ ca Y7 1A r Ci . r . <br /> Print Name f i.ylyy-1� J .7 £ 1 Date QJr� z4l D <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued IG .-- Q Z Area obi¢ <br /> VE _— 3 <br /> Grout Inspection By Date Final Inspection By .: sv In �,:'u :,a (V% <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMr EO CHECK ## RECD BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 3501 g 6 p ?+.15 SR# DL� <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc 1/25/02 <br />