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ORIGINAL. <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 <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 Joaquin County <br /> Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> //y�L !�J p G� Assessor's <br /> WELL Location I 's�G1_(� ci Cross Street Cit4j� TMJ`.QZ1 J� Parcel# <br /> PROPERTY Owners r"'� ��11Address �0 SCity Sihone# q�2- /�2� <br /> C-57 Contractor��r' I dress 5 U I`16U� /IUC_,,City / 4 _ is ;'hone# <br /> � it � Lic# Phone#Consultant/Sub Contractor � �4�(, <br /> 7 <br /> �- <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFOR(5� <br /> ,WNEW WELL/BORIN EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> 2,5011-BORING# 0 OVER-BORE <br /> 0 WELL# O PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> H MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE "ham LTIPLE CASINGS?a YES/ 10 WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS A1jPr TYPE OF CASING: 0 STEEL O PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL e-17-)%U— TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE g<USH POINT GROUT SEAL PUMPED:)yPes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,,g-SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Ia,4"- <br /> p <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH ~ 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> UCTOR CASING PROPOSED? (if YES,list specifications here): <br /> `COMMENT �I� �OZ � �' <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. , / L <br /> Signed x (�/l�.V� � Title/Company 'Q <br /> +�7 /n7t J � ttf7 <br /> Print Name &I,) f <br /> ,, �/c 4u— Date <br /> l p 1 LA, Q <br /> DEPARTMENT US'E1 ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3` 11 7 lAlf a (1jji VV�, S-lZr.,C <br /> WORK PLAN DATED: /--;Z 21)v \j t <br /> Application Accepted By Date Issued —12- Are. <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date D� <br /> COMMENTS I CONDITIONS: op if owwwo <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DAT PERMIT I SERVICE REQUEST# INVOICE <br /> 3501 /10 m /7 (a // o SR# &WIll <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ c! 1/25/02 <br />