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F11 <br /> WELL PERMIT APPLICATION FORM 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 O Al • 6P <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 /> 421 Cfl�f�l. A cAP,4 /AVE• Assessors <br /> WELL LocationXV Q, Cross Street TN oAn�" AD City L pas; Zip q$L Parcel# <br /> P�o1s�pEs F �/y <br /> PROPERTY Owner 1L/,e0i}FC CArTAe� AddP.T. 0. Bex IYl/ Ciry W� �O� 1 Zip 95'1'sa Phone#109-3� 7 95!5QC-57Contractor AJUA tctD ^Q�" Address 837 51yA,v AP. ciry�Sr�TxKr�r.zip StrtLjc# 694" ahone#ts5 'VIP )^I00� <br /> Consultant/Sub Contractor A• �s• r--. Address 83 7 394,,J RD City STOC.r-Tan Lic#6 _g Z 2 ;hone#5 09- y1i 7 -/Do If <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 1rNEW WELL/BORING(CPT, E PRO YDR,QPUNCH,H D-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> ,i�` A SOIL BORING# 1•31e I 3 7 a OVER <br /> 0 WELL# 0 PRESSURE GROUT <br /> *Other: W m.0 - Gjout Specifications: <br /> COMMENTS: S£� OVQD WORK /cn QO fi�� b9 AIA Z OO 'Z <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE? ' MULTIPLE CASINGS?0 YES NO WELL CASING DIA~ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NIA TY EpF��CC}}ASING: 0 STEEL 0 PVC 0 OTHER: N1.A <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL�j+d L_ t TREMIE TYPE TO BE USED: OAUGERS �FiOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yews �kNo (NOTE: MAXIM EE-FALL DEPTH IS 30) <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: FI k�IO_T AD /�1- <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH d5-5F f 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?N/117 (if 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 Ordinance's, Rules and Regulations, and all applicable California rAState Laws. <br /> Signed x_ i�--� - sfiRr—' Tifle/Company [y!101 Er <br /> Print Nameyy , <br /> --rr0Tr',� C l/ � Date �y 2 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,AD SS: �V/ U/e �E w <br /> WORK PLAN DATED: AIA4 <br /> Application Accepted By Date Issued / old L� Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# cease <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC-D BY I DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC,/ -WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc 1/25/02 <br />