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WELL r �RMIT APPLICATION FU 1 SITE <br /> 01 (-, MITIGATION <br /> SAN JOAQUIN COUNTY � � N�,IV I�- <br /> 11I ENVIRONMENTAL HEALTH DEPARTMENT (EHD) _�(_ �� ,� 11' E U <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 - <br /> g� (209) 468-3449 F E t3 4 200: <br /> NON-REFUNDABLE PERMIT.EXPIRES 1 YEAR FROM DATE ISSUED G��1l�R �� T <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicatiort+sMrMBtl�iri� I ai ntie aVith4an <br /> Joaquin County Development Title,Chapter 9-1(115.3 and the Standards of Stan Joaquin County/Environmental HealthpDepartmeRr-R!'AMS-r�VICr-� <br /> WELL Location 9 D-7� Sven k e,d �do Cross Street CO 1�.cc- �Gity A GG y►� Zip N o�O"' Parcel#Assessods <br /> PROPERTY Owner �E� ¢ �60ra T`1� 11PX Address SQMC� City Zip Phone# "?- 173 <br /> STS` Zi 7�-70}�Lic# Phone# yL7` /OQfo <br /> C-57 Contractor AGF Address 9 31 S aw IZA City p <br /> Consultant ISub Cntr Address City Lic# Phone# <br /> GIS Coordinates!X ,Y Township Range Section <br /> 1 <br /> WORK TO BE PERFORMED: <br /> ,NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) [�DESTRUCTION (choose type below) <br /> $,SOIL BORING# Ses- 1 5 b'Z Q OVER-BORE <br /> Q WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I}MONITORING 0 HOLLOW STEM DIA,OF BOREHOLE_,� �MULTIPLE CASINGS?0 MULTI-LEVEL?0 WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL U PVC l]OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS p HOSE <br /> d AIR SPARGE I Ozone 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 20') <br /> SOIL BORING -"HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: G OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or I]STOVE PIPE <br /> ` CONDUCTOR CASING PROPOSED? fbd (if YES,list specifications here): <br /> "COMMENTS: �af r n SQ c,.1eJ W;+ ' <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 Ordina es, Rules and Regulations, and all applicable California State Laws.r <br /> Signed x Q M 1 Title/Company t/i r 0 Nr4b'�YL t 9-ciaj%Sj` l4�a <br /> Print N@ <br /> -tier Date C))--oy- o3 <br /> (DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: (::PW7(o 7(o <br /> WORK PLAN DATED: D'> e p{� <br /> a�� Area <br /> Application Accepted By Date Issued - <br /> Grout Inspection By Date Final Inspection By ate <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 032. C» 321 <br /> C-57� WG -WAIVER C-57 Letter of Authorization to sign p rmitn— Encroachment doc^ 8/29/02 <br />