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WI`I_.L PERMIT APPLICATION FbR641 SITE <br /> SAN JOAQUIN CO JNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EAID) MITIGATION <br /> ' �'= UNIT <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 7 EAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor instal 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. j <br /> II ('�yv / Assessors <br /> WELL Location +�1� GS+ N�dJ� . Cross Street —City- <br /> PROPERTY( <br /> ity (+tSR Zipp C� Parcel# <br /> PROPERTY ` r��iOS <br /> Owner` C{`�,., Address�[D C w�Yihc��_ S� City— ra Zip��jPhone# <br /> C-57Contractor �QLJ�� Address A Z�� ity f-�lU�?0 Zip Lic#��.Pho�ne# 116 ::3F �" <br /> Consultant I Sub Cntr / t[J'�- Address kc,� City�7 Lic#�>'�ZPhorfe E '�93vv <br /> GIS Coordinates:X Y Township Range Section { <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/ BORING (CPT,GECPROBE,HYDROPU NCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> OIL BORING* 0 OVER-BORE. DIAMETER <br /> PVELL# R a PRESSURE GROUT <br /> a'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFIC A IONS it <br /> 0 MONITORING 0 HOLLOW STEM DIA,OF BOREHOLE_q�ti ©14ULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: I v <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS J�J' TYPE OF CASING: 0 STEEL 'j'PVC BOTHER: <br /> 0 VAPOR MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: B AUGERS a HOSE <br /> r-�IR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes �lo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> J0 _SOIL BORING H HAND AUGER GROUT SPECIFICATIONS �JG' } '[[iU�? <br /> []OTHER: 0 OTHER APPROX.BORING DEPTH D� U4OLTED TRAFFIC BOX or 0 STOVE PIPE i <br /> CONDUCTOR CASING PROP DSED 40 - (if YES,list specifications in comment section) <br /> C-IMMENTS: n-E D <br /> NOTE: OFFSITE 80RINGS REQUIRE ACCESS AGF EEM SIT R ENCROACHMENT ERMITS. <br /> 48 WORKING HOURS NOTICE REQU RED FOR INSPECTIONS. <br /> i hereby certify that I have prepared this application and that the-- ork will be done in accordance with San Joaquin <br /> County Ord' nces, Rule and Regulations, and all applicable Ca ifornia State Laws. <br /> Signed x c Title/Com pany t�Cci q es 1,4r <br /> Print Name ok V\ L R Date 0 <br /> DEPARTMENT U E ONLY i <br /> SITE MAP IN UNIT IV FILE,ADDRESS: k V Wtnn I <br /> qj- <br /> WORK PLAN DATED: IIIc / <br /> Date Issued S fC D Are 6 L i <br /> Application Accepted By ['Gt. I <br /> Grout Inspection By l ..� d� Date S' 3 C`f Fina Inspection 13y Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> F[ACCOUNTING ONLY: AID# FAC# <br /> CODES FEE INFO _ AMOUNT REMITTED CHECK# REC'D B DATE PERMIT I S CE R.E U IN E <br /> 5-C� ) csc�,oc� Zo3y�{ � s e o 3 9 <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit Encroach ent doc�— 9/30/02 + <br /> i <br /> l <br />