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u <br /> ORIGINAL <br /> WELL PERMIT APPLICATION FORM SITE M <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 V 'V <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 h <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> _ (,, Assessor's r's <br /> WELL LocatiY 4 1 v ( Cross Street Zip ZoPacel# <br /> PROPERTY Owner Ve��� ��0(4L� Address77'� PlCity� it�ip� Phonv# <br /> C-57Contraeto / lestS Addres'.iJ ) Cityj <br /> + LZip `t' a iL�# ?Phone <br /> r 'jy q C. [C��IhIG# Phone#w(�/ VY✓ <br /> �'r�-�. tyS�c <br /> Consultant!Sub Cntr �?C Address, tti Ci <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO 8£PERFORMED: <br /> EW WELL!BORING CPT EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) DESTRUCTION(choose type below) <br /> a SOIL BORING# OVER-BORE <br /> WELL# [I PRESSURE GROUT <br /> `Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFtCAT ONS <br /> p MONITORING p HOLLOW STEM DIA,OF BOREHOLE MU kE CASINGS?Ij MULTI-LEVEL?a WELL CASING DIA: <br /> U EXTRACTION []AIR HAMMERIDRIVEN CASING THICKNESSA/A TYPE OF CASING: 0 STEEL 0 PVC D OTHER: <br /> 0 VAPOR MUD ROTARY DEPTH OF GROUT SEALk -C- TREMIE TYPE TO BE USED: O AUGERS a HOSE <br /> p AIR SPARGE!Ozone <br /> ,,�USH POINT GROUT SEAL PUMPED: Uses 0 v (NO- E: MAXIMUM FREE-FALL DEPTH IS 30') <br /> '0116Olt BORING [j HAND AUGER GROUT SPECIFICATIONS: P(? ' <br /> D OTHER: {j OTHER APPROX.BORING DEPTH 1.30 F-C-Z-0— U BOLTED TRAFFIC BOX or a STOVE PIPE <br /> 3 CONDUCTOR CASING rOPOSED7_)_(if YES,list specifications here): <br /> 'COMMENTS: '� 1M <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 /> R0& <br /> Signed TitlelCompany, / <br /> Print Namel(kz �(-. _ _ Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 3� 44�e__y c �� <br /> WORK PLAN DATED: C WED <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection B jDate Z 4 ­03 <br /> Destruction Inspection By Date <br /> cOMMENTS!CONDITIONS: <br /> I <br /> )kCCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit qef Encroachment doc 8/29/02 <br />