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WELL PERMIT APPLICATION FOR 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 <br /> z Z Z 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 Joaquin County <br /> Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> n <br /> WELL Location /� / Assessor's <br /> / : /T/� Cross Street 5 G%� City, �C/rL� Zip�s�� Parcel# /(U� _Assessor's <br /> PROPERTY Owner <br /> /I�H�+Jhp ��1�t/ �- Address �++�b/�,T04f S Citys'r� Zpy�s�4phone# <br /> ' 77 one# �I - ��C57 Contracdress�` t p <br /> Consultant/Sub Contractor /'t� Address 163.)'5k-A')1-4 City��104'1 c# Phone#.?>i V6,7- <br /> GIS <br /> 1GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> ,eSOIL BORING# 0 OVER-BORE <br /> WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'MONITORING ,g-t�OLLOW STEM DIA.OF BOREHOLE r t MULTIPLE CASINGS?0 YES jj M WELL CASING DIA: 2 n� <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL,,ff'PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL C/)± R— TREMIE TYPE TO BE USED: <br /> �IJGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes_'N <br /> o (NOSE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: ,/� <br /> 0 OTHER: —0 OTHER APPROX,BORING DEPTH &O FZa� ILBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> \ 'CON/DUCTOR CASING PROPOSED? (if YES/,list speciificabons here): <br /> `COMMENTS: WeVr <br /> Its—( <br /> Ij <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 County Ordinances, <br /> Rules and Regulations,and all applicable California State Laws. <br /> l) <br /> Signed x '�vC'66-e' kTitle/Company 10 (sl- <br /> Print Name k;1-11 G-14-1 Date Z <br /> `DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 22 J d <br /> WORK PLAN DATED: I/l1 V <br /> Application Accepted By V ate Issued Area <br /> Grout Inspection By L Date Final Inspection By Date <br /> i <br /> Destruction Inspection By ate <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# a Z <br /> C-57_ WC--WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc_ 1/25/02 <br />