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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> C 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMTr 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 Tide,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> rn ..}.. Assessors, <br /> WELL Location-14� c5R-t-���� (=0"Cr ss Street in�aSl City�11' _zlpg62�Parcelu 04-7—.3�i`'-04' <br /> PROPERTY Owner Zu%d j )WeA 67 ' 16* Address 1971 ��'L�f �'_Clty t/"P I Zip Q�Phone#/ �`'A' <br /> Cbl ContradorY� ,.7 Adderew p bo><' (!o CityTS/e-fa„ ;� �Li 1 �Phonefd r1�607 7-'yta6 <br /> Consultant/Sub Contractor <br /> • I�(' Address) LaWlV S' city '" rl l' c# iV Phanef���/(0•'�l�yl� <br /> GIS Coordinates:X..Y .Township Range Section <br /> WORK TO BE PERFORMED: <br /> 1]NEW WELL/BORING(CPT,GEOPROBE,HYDROPUN HAND-AU R, THER7 DESTRUCTION(choose type below) <br /> SOIL BORING# c'� Z- 1]OVER-BORE <br /> WELL# 0 PRESSURE GROUT <br /> .O�Qr. Grout Specifications, <br /> COMMENTS: <br /> TYPEOFWELL INSTALLATION'TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING 1]HOLLOW STEM DIA.OF BOREHOLE '/t4 MULTIPLE CASINGS?0 YES AID WELL CASING DIA:! <br /> 0 EXTRACTION p AIR HAMMERIDRrVEN CASING THICKNESS TYPE OF CASING: JISTEEL 0 PVC II OTHER: <br /> 11 VAPOR (]MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br /> a AIR SPARGE "PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE:yM KIMUM FREE-FALL DEPTH IS 30') <br /> [OIL BORING []❑HAND AUGER GROUT SPECIFICATIONS: C- �\ <br /> OTHER fl OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or )]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?W(If YES,list specifications here): <br /> "COMMENTS, �-�Ut�l /J•�4S /I 2 /76� <br /> l ; <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 Ordin c s, es an ulations,and all applicable California State Laws. <br /> Signed <br /> r F e 6-rozAxd -T,deloompany <br /> Print Name �fl Cx C Date Co —Z 7-G Z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 5 " <br /> WORK PLAN DATED:` M -1 7 D <br /> AppOcation Accepted By -�y;_ b r\ a_o w_:, Data Issued I ( � I Area C� <br /> Grout Inspection By �`IC>ti'�'LR l e 7�15� Oz- FlnaI Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> E;AC;C0UNTjNG ONLY: AIDR FEEINFO AMOUNTREMITTED CHECK# REC'D BY DATE PERMIT/SERVK:E REQUEST 0 INVOICE SR* o y Lffl <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doci 1/�5/02 <br />