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.� FILE COPY <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 OFF- S516P <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a pem it to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter <br /> ,,9-1115.3����11and the Standards of San Joaquin County PEnvironmental Health Department.lAssessors <br /> S IIIA WA�k 'DZI S,U/j(SON wdA Cross Street 1--61 City J N Zip�ZParcel# <br /> WELL Location ��,, ���1rr�� of q <br /> PROPERT't,. h gddress 345 Al CIbDfA V CIh =Zip 1K Phone# �37 -g�j'� I <br /> Owner l <br /> l��vaacee� C�eoEnu Address 5�"Qr+1 r rt CIIY�tJ![tr�N—Zip LI ��r� <br /> C-57 Contractor ) <br /> 11 / V Addn / <br /> Consultant/Sub Cntr t��1n u/(� >/O QIress S544,0pct City Lic# 6 Phone# <br /> Q <br /> GIS Coordinates:X <br /> Y ,Township Range Section <br /> WOFO RK 70 BE PER <br /> --NEW WELL NG CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 LL# 0 PRESSURE GROUT <br /> O*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING 0 HOLLOW STEM DIA.OF BOREHOLEJ �L 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS r TYPE OF CASING: 0 STEEL 0 PVC ]]OTHER:_ <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 4tA4i r2 TREMIE TYPE TO BE USED: 0 AUGERS p HOSE <br /> p AIR SPARGE/OZONE %PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 1��1o'(NOTT�: MAXIMUM FREE-FALL DEPTH IS 30') <br /> )I[SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS , - Q Ut <br /> 0 <br /> OTHER:-O OTHER APPROX.BORING DEPTH Q57-5O/ 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CCNDUCTOR CASING PROPOSED A)J (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR 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 Re/t.ulations,and all applicable California State Laws. .a�1 <br /> Signed Y`^ Tille/Company ! 1eD( r'L♦1+aucPd GtoEuvir��t+c� <br /> Print Name 12ff <br /> "ne- Date <br /> Q�DEEPARTMENTU/SE®®ON-�ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: O!/-1 5. <br /> WORK PLAN DATED: :7-1 8-O Z ff <br /> Application Accepted By Date Issued Area V <br /> Grout Inspection By Date Final Inspection Date ' D' <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATEtPERMIT�lSERVICE REQUEST# INVOICE <br /> Z-13<0 9 33 <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br /> -#6 ­es3 <br /> Ole— -to 3- I— <br />