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07:' 1712002 07: 53 209468343" FIFTH FLOOR PAGE 02 <br />WELL PERMIT APPLICATION FORM 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 YEAF�FROM DATE ISSUED <br />4ppllc2tion 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 />Assessor's <br />WELLLocatlonlLo)'i WeS� Fc-e-moy4AV`s Cross Street -=-5 cityycKiOn Zlp9s�203 Parc.El# 135-Ild- /,�- <br />PROPERTY Owner )a c '�Rkc1Xe.0 Co Addmss '?-0--i6oX (2!G45 City Mce ° cJoL Zip 9 ` 570 Phonerlq <br />C-57 Contractor Exp�oloi�ori AddEs53�3C`nc�..rtcl�, A/e- City l�' ocy-1 Zlp'?S7l,SLic#-SSS4oPhone#;9i4)Y3�-yao0 <br />)� �000 <br />Consultant / Sub Contractor LD RS Address ys4 ie 3oeCity c�aww ick Phone 914, <br />VIS Coordlnates <br />Y <br />Township_ <br />WORK TO BE PERFORMED: <br />f NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH. HAND -AUGER, OTHER") <br />D SOIL BORING # <br />tl WELL # - <br />`Other, <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />MONITORING (3) <br />1 HOLLOW STEM <br />D EXTRACTION <br />0 AIR HAMMEWDRIVEN <br />p VAPOR <br />p MUD ROTARY <br />(] AIR SPARGE <br />D PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />Q OTHER -._I] <br />OTHER <br />-COMMENTS: PIe�Sc-P'JJec <br />Grout Specifications:, <br />Range Section <br />p DESTRUCTION (moose type below) <br />0 OVER -BORE <br />a PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS <br />DIA- OF BOREHOLE 2? -5- MULTIPLE CASINGS? []YES I NO WELL CASING DIA- 02 - <br />CASING THICKNESS -'C� '!/:�O TYPE OF CASING: []STEEL I PVC IJ OTHER: <br />DEPTH OF GROUT SEAL 3.51 TREMIE TYPE TO BE USED' A AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes I No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: 1't -e a � Cen Le ✓L$- <br />APPROX, BORING DEPTH .2-6II BOLTED TRAFFIC 13OX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br />.o�an dated <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 -✓ 1 L Titl^elC1ompanly ( (-- I � `-' K-� 4-- <br />t a.r o r� b ���a tl� 144- - ��} z t2. �1� to "; �- L I� <br />Print Name a rr� r. ` <br />DEPARTMENT USE ONLY. <br />C-57_ WC= WAIVER_ C-57 Letter of Author,z5Ito sign permit Encroachment doc_ 1/25/U2 <br />ACCOUNTING ONLY' <br />Al D# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />SITE MAP IN UNIT IV FILE, ADDRESS; <br />REC'D B <br />DATE <br />U <br />WORK PLAN DATED:%�g/� <br />V` <br />Z9 <br />j <br />`'' `' Area <br />By <br />Application Accepte�,, <br />-" <br />Date Issued ` <br />Y <br />Grout fAspeotion By <br />Date <br />Final Inspection By <br />ate�e�ll-� <br />Destruction Inspect�Sy <br />Date <br />-nuueure r r n► nrnn�lc. <br />i,r G,6 4 <br />`' CL <br />C-57_ WC= WAIVER_ C-57 Letter of Author,z5Ito sign permit Encroachment doc_ 1/25/U2 <br />ACCOUNTING ONLY' <br />Al D# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D B <br />DATE <br />PERMIT! SERVICE REQUEST li <br />INVOICE <br />�4.00� <br />Z9 <br />aZ <br />sR�t ob <br />C-57_ WC= WAIVER_ C-57 Letter of Author,z5Ito sign permit Encroachment doc_ 1/25/U2 <br />