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L_ WELL - =RMIT APPLICATION FC - M HLEE OPT <br /> SAN JOAQUIN COUNTY MITIGA <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> n " 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> J I (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 Ei lance w h San J <br /> Joaquin County DeveloDmment Title,Chapter 9-1115.3 and the Standards of San Joa uin ounty Environmental Health Department. <br /> jy Ne / jjlni Sf Cjy�. Assessor's <br /> WELL Location mss Street (N City Zip�1SZa f Parcel# /17-dg- 27 <br /> PROPERTY <br /> Owner rctr^ Address 0q IV Pn4144 CityS�K+�T✓1 Zip�ZaSPhone# Zol- 953.yL90 <br /> is'fi�c!^ 9Ay_40 0577- <br /> C-57 Contractor Address City 6,0&.0, Zip yr7'/LLic#7i7S/o Phone# <br /> Consultant/§ub r /,1/( 31A/ <br /> /� /� <br /> Contractor Qts 61✓+ �ddress �7 .33 A/ 3 � City /Aoe41V Lic# Phone# 4_o 2-7Z$-o 707 <br /> 2 8t'oo3 <br /> GIS Coordinates:X 121 IL 7 It.6 + ,Y_ ,wnship 2N Range ZW 6F--Section- <br /> 1-7. 3a <br /> S$' j j.87 <br /> WORK TO BE PERFORMED: <br />,NNEW WELL/BORING(CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> R WELL# n'1 V-!1 a 0 PRESSURE GROUT <br />'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ;RHOLLOW STEM DIA.OF BOREHOLE /� �! MULTIPLE CASINGS?)(YES 0 NO WELL CASING DIA: 2- <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS �•1f`/ TYPE OF CASING: 0 STEEL APVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 6193Z' TREMIE TYPE TO BE USED: if AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes )INo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: /UG4,7—Ce~�&-ee-JZ7 <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH $S, )XBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specificationshere): <br />'COMMENTS: Ze q 5"r 9e iTj 6­ <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 / /' � Title/Company byR M►T: 1610-e.. <br /> Print Name Bd'��IYI c04W1� Date 7-1157­16 2- <br /> DEPARTMENT US <br /> DEPARTMENTUSEONLY p <br /> SITE MAP IN UNIT IV FILE, ADDRESS: ,701 l�Z, �/- <br /> WORK PLAN DATED: /'�'D/ t -/�'�� ' LDiZ3-C) Z— <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By <br /> Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# cnr4+ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#q RECD BY DATE PERMIT/SERVICE/REQUEST# INVOICE <br /> MW <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br />