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-F OPY, <br /> -ILE C <br /> WELL PERMIT APPLICATION FORM R SITE , <br /> DSAN JOAQUIN COUNTY MITIGATION <br /> UNIT1VENVIRONMENTAL HEALTH DEPARTMENT(EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA, 95202 <br /> (209) 468-3449 .. <br /> NON-REFUNDABLE PERMIT EXPIRES i 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 /> �gu, � Assessor's _ <br /> WELL Location Cross Street j Cit Zip 52a Parcel# - <br /> PROPERTY Ownner `J]�iKa)`odl L./�11 J Address -70) � 5�5/2�EG�i� hone# /���t��" <br /> C-57 Contractor`lI` 'I 1 dress/�t7 d6we— :��ity (. �i�j-hone# '7 DC7 ���.'� <br /> Consultant 1 Sub Contractor(') Address 8.•37 SAaL.I Pjee-,City�Zic# phone# 49�`,/PZ)�o <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFOR D: <br /> EW WELL 1 BORIN (CPT EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) [10 ESTRUCTION(choose type below) , <br /> SIL#ORSNG#5 n. n27 _ 0 OVERBORE <br /> `Other: Grout Specifications: 0 PRESSURE GROUT- <br /> COMMENTS: , <br /> F: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE the LTIPLE CASINGS?0 YES do WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NP" TYPE OF CASING: 0 STEEL 0 FVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL e- TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE RfTUSH POINT GROUT SEAL PUMPED:Jyfes 0 N-Jr <br /> o ((NOTE:MAXIMUM FREE-FALL DEPTH IS 30') ✓ <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Irl Q-T -cnOL _ <br /> 0 OTHER: Il OTHER APPROX.BORING DEPTH �" r 0 BOLTED TRAFFIC BOX-or 0 STOVE PIPE <br /> UCTOR CASING PROPOSED? "(if YES,list specifications here): i <br /> *COMMENT <br /> ITE 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 <br /> Regulations,and all applicable California State Laws. <br /> S'sgned x W � Title/Company <br /> Print Name Zd2, / c �i...— {�� Date <br /> DEPARTMENT US,E ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_ { r" { w6Us G rte` <br /> WORK PLAN DATED: /aL 2ID R p <br /> i. Date Issued [� r �^ `� Area <br /> Application Accepted By <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DAT PERMIT!SERVICE REQUEST# INVOICE <br /> 350 lb 907 'SR# <br /> C-57 V WC_-WAIVER C-57.Letter of Authorization to sign permit acaea c_ 1/25/02 <br /> -- _ <br /> _2 <br />