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0R1 <br /> WELL PERMIT-APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> np1 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 /> /n Assessor's <br /> WELL LocatIOL. l 5Z r_ �/�l C /T�� ross Street r �b r� City- �L j( Zlp S S Parcel# <br /> I n 0-�j t2 <br /> PROPERTY Owner yl Address f �kl� itv56a e,' OA Zi t.-2D�PYone# Tip' 73 7 � 3 <br /> / <br /> C-57 Contracto r� ,G" Address150 „ ' City , i �5Ey5 JLic# Phoo1nze# <br /> Consultant 1 Sub Cntr Addressy3,2 `f1i?k)L, Ciy:&_e_g4-4_LIc# Phone#, 5 311t 63 <br /> G15 Coordinates:XY Township Range Section <br /> WORK TO 13E PERFOR <br /> "EW WELL!BORI (CPT EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> OIL BORING# 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> "Other: Grout Speclfi tion j <br /> COMMENTS <br /> TYPE OF WELL INSTALLLA ON TYPE CONSTRUCTION S ECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE M RE CASINGS?0 MULTI-LEVEL?0 WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS AIA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER:- <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL t TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE 1 Ozone&PLISH POINT GROUT SEAL PUMPED: , Yes 0 No ([ROTI=: MAXIMUM FREE-FALL DEPTH IS 30) <br /> FOIL BORING a HAND AUGER GROUT SPECIFICATIONS:,.P06lt1�- <br /> D OTHER: 0 OTHER APPROX.BORING DEPTH_/yam F -f- 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> `COMMENTS: 5 Vow, ylf - — &Cly 6"S/ <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- VG A_ Title/Company- A C36 jT <br /> Print Name , L A—A,_1 ' Date <br /> DEPARTMENT USE ONLY q <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: / � �b <br /> Application Accepted By Date Issued Area (/ <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> JJ <br /> COMMENTS I CONDITIONS: v7/` <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R CID BY BATE ' PERMIT I SERVICE REQUEST# INVOICE <br /> ® 1 ? 3A? <br /> C-57 '-/ WC_-WAIVER C-57 Letter of Authorization to sign permit Enc oachment doc 8/29/02 <br /> rr_V7 <br />