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WELLIERMIT APPLICATION F t 'M SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (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 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 /> M A N i F-C JE55i� 5tf'K} M�/1��11 A Assessors <br /> WELL Location-C ±-uEn \- ' j - cross Street! 5em& A�N& City ELIV MQC-I Zip 9553(. Parcel# <br /> PROPERTY Owner C174 MAtTma WfAI ?` Address 1C I W, ( pn.+a/- CityCQ Z;p95337 Phone# 410 llr <br /> povq ZipaS Uc# 9q, gPhone#414, 63F 1165 <br /> C-57 5�contractor C sc F- D ; Address �11:03� O�nP� rc��alJ <br /> Consultant/Sub ContractorAAv&/ceD fnv,ren+nwa'A,ddress $,J�] Sf)Hv.I R�• CityStocl('?onLic#(D8o227Phone#�o9 y67/DO <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 9 DESTRUCTION(choose type below) <br /> Q SOIL BORING# I1 OVER-BORE <br /> ELL# MW^/Q � m W 0 PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> `5 <br /> COMMENTS: ct- / W C Z a 0 Z <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING OLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?a YES O WELL CASING DIA: z <br /> n' RACTION AIR HAMMERIDRIVEN CASING THICKNESS yo C TYPE OF CASING: 0 S EL a PVC/DTHER: Qbt <br /> u VAPOR ()MUD ROTARY DEPTH OF GROUT SEAL !- P�• • TREMIE TYPE TO BE USED:,,�"UGERS a HOSE <br /> 0 AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: U Yes )Io (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING p HAND AUGER GROUT SPECIFICATIONS: o T ti <br /> a OTHER: Il OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?N o (; YES,list specifications here): <br /> "COMMENTS: <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 Californi Tae Laws. <br /> j � l r <br /> Signed x C Tille/Company �f�T 11/0 5? 'U•�— <br /> Print Name / =y V / Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued T ` l / Area — <br /> Date Final Inspection By Date <br /> Grout Inspection By - <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# �nre <br /> PE CODES I FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# JINVOICE <br /> l-4 (-6q 110/07 SRA 313 O 'Z <br /> C-57_ WC=WAIVER_ C-57 Letter of Autho z Ion o sign permit_Encroachment doc_ 1/25/02 <br />