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ORIGI <br /> K <br /> L <br /> �oWELL PERMIT APPLICATION FORM SITE <br /> MITIGATIONSAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 d N <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,,�/C�haapptteer�I�/9-111/115.3�annd the Standards,of(San Joaquin County Environmental Health Department.�sessor's <br /> WELL Location� S C@Y.�fi ''i/• Cross Street �" 11�7(1� Citys� t� Zip1 Parcel# d9 Z - 2,6-60 <br /> // 7 <br /> PROPERTY Owner )U_U.S efZ(g/,6, Address lIIOKT j��/ - C7�.Ciry laC Zip W97 17/��T <br /> C-57 Contractor(Ts�� <br /> Lj4jjL 0jVLt1A&ddres > S WAf7- h-VL- City S Zip Lic#4,7ZP6'7 Phon 9/l(oX�3/- / � <br /> Consultant/Sub Cntr <br /> r _ Address n�7 �UtAt-✓ K(/. City ii�� ic# � 2-7 Phone# ry 7- b 0,t� <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW ELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OT * �Z p DESTRUCTION (choose type below) <br /> o SOIL BORING# f v Q OVER-BORE <br /> 0 WELL# W f 0(b 17 PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE '' MULTIPLE CASINGS? MULTI-LEVEL?Q WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSSC o �6 TYPE OF CASING: O STEEL KVC 0 OTHER: <br /> Q VAPOR 1]MUD ROTARY DEPTH OF GROUT SEAL VAIejju t TREMIE TYPE TO BE USED: AUGERS HOSE <br /> 0 AIR SPARGE/Ozone PUSH POINT GROUT SEAL PUMPED: Ye n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: t -� <br /> 0 OTHER:_O OTHER APPROX.BORING DEPTH 4 WhOLTED FFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? tj6 (if YES,list specifications here): <br /> *COMMENTS:1000' P464M'. <br /> o <br /> NOTE: OFFSI E 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 pre red this application and that the work will be done in accordance with San Joaquin <br /> County rdi a e ul nd egulations, and all applicable California State Laws. L <br /> Signed Title/Company$TAX� Wo 1��7 M /tlL L <br /> Print Name i. Ong Date d7 <br /> DEPARTMENT USE ONLY�Q� <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 335 �• '" I��P� <br /> WORK PLAN DATED: 2,-Z F-202, <br /> Application Accepted By Date Issued Area <br /> Grout Inspection ByDate Final Inspection B�"" � �+Date 1- 6 -O 3 <br /> 11 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS. <br /> Ayr VIM411 <br /> FACCbUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R 'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc 8/29/02 <br />