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u, WELL PERMIT APPLICATION FORM SITE <br /> aLL MITIGATION <br /> = SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> u"= `" 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> Ou. ca <br /> 0 <br /> 1 N NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> O <br /> Applioatlon 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 an <br /> Joaquin County Development Title,Chapter 9-7115.3 and the Standards of San Joaquin County Environmental Health Department.Assessors <br /> 1/ •T i l-tea V/Parcel# <br /> WELL Location Y 'I an c8t. �.- ye Cross Street E'•D4K St City �-� Zip �� y Phone# <br /> V' _ Address_ 60h I_aI r�—City Lo, _Zip�— <br /> PROPERTY Owner U'f I / <br /> GI'. City Rot,da Zi�/57 Lic#.�hone#`/ /6 / <br /> C-57 Contractor P•5n(1!(�L frl�!� dress 3611 2J^/�^•Z( � Lim �U phone# 7(i7�UUb <br /> Consultant/Sub Cntr /SIN Address�J / S�^�L City <br /> Range Section <br /> GIS Coordinates:X y.,Township <br /> WORK TO BE PERFORMED: p DESTRUCTION(choose type below) <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') a OVER-BORE <br /> SOIL BORING# 5 a PRESSURE GROUT <br /> JELL# — <br /> Grout Specifications, <br /> *Other: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECgIF1I,CA�ULTIPLE CASINGS?DMULTIONS -LEVEL?l] WELL CASING DIA: <br /> _ <br /> ONITORING OLLOW STEM DIA.OF BOREHOLE S��E OF CASING: U STEEL <VC O OTHER: <br /> o EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL XO 1�0� TREMIE TYPE TO BE USED: tCUGERS ()HOSE <br /> p AIR SPARGE/ozone []PUSH POINT GROUT SEAL PUMPED: p Yes ANO ( OTE: M IMUM FREE-FALLL DEPTH IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: p� ,5l4 H, )dtcl BOLTED TRAFFIC BOX or STOVEPIPE <br /> OTHER: Q OTHER APPROX.BORING DEPTH - <br /> CONDUCTOR CASING PROPOSED? (If YES,list specifications here): <br /> *COMMENTS: nAc 'Cly I <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 Ordi noes, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company CJG����� ) <br /> r (�✓7 Date �� D/ 02— <br /> Print Name— <br /> SITE <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: rOd� <br /> WORK PLAN DATED: <br /> Date Issued <br /> Area P Oc <br /> Application Accepted By Dated LO <br /> Grout Inspection By <br /> Date !Z 0 D Z Fnal Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: O/U <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMITd�?�� O VEST# INVOICE <br /> 1 no 7 / X'je l S 8/29/I <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign ermit_Encroachment doc_ <br />