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'MY <br /> �j DLL <br /> WELL PERMIT.A ?P-�ICATiON FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENTEHD UNIT IV <br /> Lr7D� 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> [...•�� 1 (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 9-9115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ISz rj�t°��ij�. J�� C Assessors <br /> WELL Lacatioc: r eet " dL r City �G / Z(! lip 1ST 3 Parcel# <br /> PROPERTY Owner ? Address' .5 / �?=j��/�} Y citySl'L2 tC li n Zj fi 3'. D,j Phone#eq6 7— 3 <br /> C-57 Contracto Addres5<50 �j- Y SSS <br /> rr���� City f�ip JLic# Phone# <br /> Consultant I Sub Cntr ° A� Addresscl-3'7 5/11,U)JU City /b5 Lic# Phone 7 y6" <br /> GIS Coordinates:X Y ,Township Range Section i <br /> WORK TO BE PERFOR <br /> ,j-KEW WELL!BORI (CPT EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-} []DESTRUCTION(choose type below) ! <br /> OIL BORING# (I OVER-BORE <br /> WELL# PRESSURE GROUT <br /> *Other: rout Specificptia <br /> COMMENTS <br /> TYPE OF WELL INSTA' ON TYPE CONSTRUCTIONS ECIFICATIONS jj f <br /> a MONITORING U HOLLOW STEM DIA.OF BOREHOLE I' S- I07IPL.E CASINGS?a MULTI-LEVEL?U WELL CASING DIA: <br /> a EXTRACTION 0 AIR HAMMERI)RIVEN CASING THICKNESS' n! <br /> ,.��TYPE OF CASING: p STEEL [I PVC q OTHER: . <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT'SEAL 6:oTREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> [)AIR SPARGE!Ozone&PL1SH POINT GROUT SEAL PUMPED: l9'es '13 No ( OTE: MAXIMUM FREE-FALL DEPTH IS 30') ` <br /> ,FOIL BORING a HAND AUGER GROUT SPECIFICATION S.'__Po "�r�, <br /> 11 OTHER: [j OTHER APPROX.BORING DEPTH A;;V a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 'CONDUCTOR (SING PROPOSED7 (if YES,list specifications here): <br /> 9 <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 Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x V u t T1tle/Company A o <br /> Print Name ' " Data <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 31,9 W�� v✓ 7 U1 ���` <br /> WORK PLAN DATED: - <br /> " <br /> Application Accepted ByDate Issued Q �d2� Area <br /> Grout Inspection By Date Final.Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# 'R C'D BY DATE '-'r ,. PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 V WC -WAIVER C-57 Letter of,Authorization to sign permit Encroachment c , , Y 8129/02 <br /> �G <br /> . k <br />