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,..r FILE Cice' C <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 61\ <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,Chapter <br /> �`�/9-111[1115.3�and the Standards of Sa <br /> n Jooaquiin County Environmental Health Department.�di- �(/ tvs?'k 7Uti� Zip� arAssessor'sl# <br /> WELL Location n '/ , / Cross/Stre/et� Ci �[/� �, Parcel# d9 2 ' `Gd7 <br /> PROPERTY Owner Y�_t1l S CSC,�t�l/�!!�-- Address(p 1 T4/?l��/9L- C�•CitY l� ZiP� rev/ Phon \7/S�T� � <br /> C-57 ContractorM(7WjU- (7OUJn�ddress53t,' S Wtt- &Vf-* CitySY-. Zip Lic#&726"7 Phon ,9l(gX�3/-;�3 <br /> Consultant/Sub Cntr • 1 - Address DLJ 7 �Ut City�4vS Lic# U22 Phone# `/(0 7-� <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHIIER* 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# W- 0 PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE "" JMULTIPLE CASINGS?0 MULTI-LEVEL?0 WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS. C-4-4 0 TYPE OF CASING: 0 STEEL KVC 0 OTHER: <br /> 0 VAPOR MUD ROTARY DEPTH OF GROUT SEAL VARjatS TREMIE TYPE TO BE USED: WAUGERS a HOSE <br /> 0 AIR SPARGE/Ozone 0 PUSH POINT GROUT SEAL PUMPED: PoYes, 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER:_O OTHER APPROX.BORING DEPTH 6 fo OLTED FFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? f46 (if YES,list specifications here): L C <br /> *COMMENTS: V✓ l - Alt / < < < B 1 J <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 1have pre red this application and that the work will be done in accordance with San Joaquin <br /> County rdi a ul nd egulations, and all applicable California State Laws. <br /> Title/Com anYS rA <br /> X 0) � l) t1i4-,J Al,Signed x <br /> Print �- <br /> Name f. � A�� <br /> DEPARTMENT USE ONLY <br /> ,Q <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 335 �• ' `a, '-� ( ��°� <br /> WORK PLAN DATED: Z'(Z-O 2- <br /> Application Accepted By Date Issued 4D Z Area aP101 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R 'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> vro/ /�z3� yI• a � & <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02 <br />