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A' F11F WY <br /> 0 M1111 low <br /> WELL PERMIT YA_ PPLICATIONORM SITE <br /> SAN JOAQUIN COUNTY <br /> MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> i <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 �� f <br /> (209) 468-3449 i <br /> y i <br /> NON-REFUNDABLE PERMIT EXPIRES'11 YEAR FROM DATE ISSUED <br /> Application 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 9-1115.3 and the Standards of Saa'Joaquin County Environmental Health Department. <br /> .<< Assessor's <br /> WELL Location Port R� ly- _ Cross Street 'T cityStocltton Zip 5203 Parcel# (4 -030-01- <br /> PROPERTYOwner O Stack on. Address �: 0"X A099 City5"l-0Ck+0VL Zip 5201 Phone#af?j:f4-0246 <br /> C-57 Contractor Pre Gi S t 0 ri _CAA I;Ma, Sddress I l�DO S, 5 J'�. City on Zip j 4 Lic#63638 Phone#31-D_.23-1-0 ZS <br /> Consultant/Sub Cntr Oin0.t1"( dress � n CityCeSno .Lic# 693965 Phone#559--161k 1$35 <br /> GIS Coordinates:X Y Township +W ----Range 6 t _Section <br /> WORK TO BE PE MED: <br /> NEW WELL ORING CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') puill� 0 DESTRUCTION(choose type below) <br /> [I SOIL BORING# 2 IoCa�TOF'l5 � r�Q hole, I a OVER-BORE <br /> [�WELL# 0 PRESSURE GROUT <br /> 'Other: Groutspeci8cations: aL0aS i -tPwleA+ dol O f iDf'+ <br /> COMMENTS <br /> F 1 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r I <br /> 1]MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 10"' MULTIPLE CASINGS?[]YES gNO WELL CASING DfA: <br /> 0 EXTRACTION . [I AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: [I STEEL 0 PVC 0 OTHER: h <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE ` <br /> D AIR SPARGE 'gPUSH POINT GROUT SEAL PUMPED: D Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: ,fle0.t- aeVAe_t%t• o rT7t&* <br /> 0 OTHER: a OTHER APPROX.BORING DEPTH NSo a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (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 <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x JYLAAA6-VI TltielCompany <br /> ee r o iS C 2.M_i 6 <br /> Print Name Date— V-10/03 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 14 -4 -6 -2— <br /> Application Accepted By Date Issued <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# &REC'D DATE�� PERMIT 1 SERVICE REQUEST# ! INVOICE <br /> /4 t-z/�o3 �LS3U <br /> C-57 W( -WAIVER C-57 Letter of Authorization'to sign permit Encroachment docl. I� <br />