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' k 1 <br /> X12 WELLERMIT APPLICATION <br /> SAN JOA UIN COUNTY FORM SITE � <br /> Q MITIGATION <br /> FEB 19 2004 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> -304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> ENVIRONME�I HEALTH (209) 468-3449 <br /> I <br /> PERW/SpVICES { <br /> NON-REFUNDABLE PERMIT EXPIRES t 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 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. € <br /> 2�� i � Assessors <br /> WELL Location iCross Street;F4atM t}4� City iC 1.1 <br /> Zip q!lY ZC4 Parcel# c <br /> PROP <br /> c <br /> owner t;2a 11 . Address phone# i <br /> C-57 Contractor 6 L$1�Lli{1G, Address'P� �C .x;��. ty tib Zp Phone#a1ZS-�13-E;S00 4 <br /> ��� -�-- Ci �p�'-f Lic#��s+65 <br /> Consultant 1 Sub Cntr Address E'b ` <br /> LrTIP-'1 tit ts�City�!KSz��1 ;Phone#qI -r;74 2 O a <br /> �SC000rdinates:X l�bSo�3Q� '', Y 4'zo407b� Township "( 2 Range bE Section <br /> z;?_ <br /> NORK TO BE PERFORMED- <br /> CNEW WELL 1 BORING (CPT,,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) <br /> Q SOIL BORING# p DESTRUCTION {choose type below} <br /> WELL#_�. t-ttJ 3i�,� _� QODIAMETER <br /> Q'Other � Q PRESSURE GROUt <br /> ;OMMENTS: �Ja cJ T"O-lt OC i;1 <br /> �S GROUT SPECIFICATIONS <br /> f <br /> ;(PE OF WELL I STALlATION TYPI= CONSTRUCTION SPECIFICATIONS <br /> -MONITORING OLLOW STEM DIA.OF BOREHOLE_ (]MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: 2n <br /> i <br /> EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESSSCI4 <L'Sn TYPE OF CASING: Q STEELVC Q OTHER: ? <br /> VAPOR Q MUD ROTARY DEPTH OF GROUT S EAL15_-_;-_--A_6 S TRE MIE TYPE TO BE USED: <br /> UAUGERS OSEAIR SPARGE1 OZONE ]PUSH POINT <br /> t' <br /> {GP or CPT}GROUT SEAL PUMPED;/ Yes Q No (NOTE: AXI UM F EE-FALL DEP fS 30') <br /> SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS C�1'YC-'� -�t � <br /> OTHER: 0 OTHER APPROX.BORING DEPTH q6 160OLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED 11,C5 (if YES,list specifications in comment section) <br /> ]MMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> lereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> aunty Ordin ces, Rules and'Reg tions, and all applicable California State Law . <br /> tned x 1L Title/Company (� � C [y <br /> LL 1 �' <br /> ntName 1 la l M1ilQ L4L-1 Date 17 <br /> D ARTMENT USE ONLY <br /> TE MAP IN UNIT IV FILE,ADDRESS: <br /> f <br /> ORK PLAN DATED: <br /> plication Accepted By 1 r'1 Date Issued 2ao.Y Area <br /> suS inspection By Date Final Inspection By <br /> Aruction Inspection By ate <br /> - Date <br /> MMENTS I CONDITIONS: <br /> f <br /> :COUNTING ONLY: AID# <br /> FAC# <br /> CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INV <br /> 35o l ;'OD 2`13 9 i x 6 0 SR# 3 <br /> 37_ WC -WAIVER; C-57 Letter of Auth Z ion sign permit_Encroachment dgc <br /> 9%30/02 <br /> l � F <br /> 4 <br /> 0e y p�. <br />