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RECENED <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> JAN 1 8 1005 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> Eh1�JWIIMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> pEpMIT/SWACES (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 <br /> c�-/{ <br /> d the Standards of San Joaquin County Environmental Health(Departmteent•Assessor,s <br /> � ✓! / 0 IV Me,;/" Cross Street /'1-AMlieL/ City G I Zip -1�5 3�`f Parcel# o?�c� � 6'i001 <br /> " <br /> WELL Location // <br /> (�l,�S�ectc� Address '�?C� &� e5 Acid City G� Zip �5>SG Phone# ad`1- $�S' <br /> PROPERTYOwner dtlLle �3 <br /> G�lr<4LIir�T!Cr✓ Zi 1 5�'SIC# /ail Phone# <br /> C-57 Contractor 1?t�ii�✓Z%� /Address u7365 � '� —City py <br /> Consultant/Sub Contractor <br /> K�{/,1� /C+!E,: Address ol��; E/1tyl4le City �'`� Lic# Phone#��i- YGS �71� <br /> GIS Coordinates:X <br /> Y Township 5 _Range Section <br /> WORK TO BE PERFORMED: �t DESTRUCTION( oose type below) <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) AIS '� IE N/� OVE e type b <br /> SOIL BORING# L 0 PRESSURE GROUT <br /> 7W ELL# It1 !' /��7 C2�ur' ��/ n �d re /lad <br /> *Other: Grout Specifications: <br /> COMMENTS: 1fexf"'4e c✓frr 5`I`� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 1/ <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE__MULTIPLE CASINGS?0 YES NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ��� TYPE OF CASING: STEEL �Kp OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL yY TREMIE TYPE TO BE USED: )(AUGERS HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: )(Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Ne.^I �'e•ket*. `Jy �r,, ry �� <br /> OTHER_ APPROX.BORING DEPTH &��— 0 BOLTED TRAFFIC BOX or STOVE PIPE <br /> 0 OTHER:_G <br /> M / /CONDUCTOR CASING PROPOSED? I�G_(if YES,list specifications here): <br /> *COMMENTS: , ` Y -1O 6,f 41 N1 1'V e�'1 f 1`e i' i( 6 <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 /> 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 /> ,/ ' Title/Company <br /> Signed x / �� <br /> Pct lt,/ Date t � -765� <br /> Print Name �*il Y �I S DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: �� R <br /> Date Issued o!' d O� Area Z <br /> Application Accepted B ' <br /> d Dates Final Inspection By Date <br /> Grout Inspection By <br /> n By <br /> Destruction InspectioDate <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# �er`ft <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# ,p RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 7ST <br /> dZ� f Dom( l� cl J O SR# <br /> Q �1ol- D O <br /> C-57 WC -WAIVER— <br /> C-57 Letter of Authorization to sign permit Encroachment doc 1/25/0, <br />