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WEL -3ERMIT APPLI1"3ATION F W SITE <br /> T SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202rii ri Hour <br /> y <br /> (209) 468-3449 YT,/ <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 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> N�r`/zcts.!Ar 709-Sb Assessor's <br /> WELL Location 27oi Al W:/Sort t,Jay Cross Street QAts;oe-17 City S1aGkr- Zip 95' 5' Parcel# //7-O$- /y <br /> PROPERTY o A 8 <br /> Owner N�/��*�t / /, Address 2?2-7N.C exr-.-rAyG City r4O e-n4X Zip 'r00Y Phone# G 2 <br /> C.0 - ZZ,3-444 7 <br /> C-57 Contractor Ce-tsex 4kd,4 Address 3-3 2 04,��Ci.^c-6e- Cit GT9- <br /> yam, rea Zipq�7`1'4ic#7/7SloPhone# g16-63S-1(69 <br /> Consultant/Sub <br /> Contractor AS/;i.956APn nWe-09 d/Address/x/3.3 N, 31-WAe CityPLt0eA1+x Lic# Phone# 602- 7219-070 7 <br /> , i� A-7- B S700 3 <br /> GIS Coordinates:X !2(- 16' 13,,75"',Y 37�Sf� �•�� Township 2 Al Range 6145 Section 30 <br /> WORK TO BE PERFORMED: <br /> ;,NEW WELL/BORING(CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER`) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> WELL# 141k 10 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE /0'Af MULTIPLE CASINGS?$YES 0 NO WELL CASING DIA:Z-Z~ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 6k TYPE OF CASING: 0 STEEL If PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 3Z� TREMIE TYPE TO BE USED: t AUGERS p HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes ItNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: *ge <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH SS ArBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> n CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: bel.,Jf;P- 5e4r Joy L cg� to /Jg �/'Elt.�a �tOSC <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 / ? �f� /f Title/Company ,4f4-3- /� /2e5 c✓�«hi mf <br /> Print Name ��`e T- �LQw��t Date Z/1 �0Z <br /> DEPARTMENTUSE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Z 7D/ V, <br /> WORK PLAN DATED: WP" 114-01 <br /> Application Accepted By Date Issued !� Z `0 2 Area 0,6 <br /> Grout Inspection By Date Final Inspection By 11 <br /> Date <br /> Destruction Inspection By Date dZ <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 350 — 2 Z•25•n2 sR# D©�q00 p <br /> C-57_ WC_-WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br />