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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 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Locatlon(�E£) >pirP�-t•t� f'njaP Cross Street City Zi Parcel#Assessors <br /> _ P <br /> PROPERTY OwneF2=1.1SLJ n�ilLtllt2� ccd'�d��ess (.fnn♦Pts(Y1A^t NO CityZip Phone# <br /> C-57 ContractoV�iXf.4)J��(A WAddressyM �?LV _ILS. CiyA zip LiJ7 Phone# 344-436c� <br /> Consultant/Sub Contractor, Sill-46W Address�V-16Cr 641""o*City dLic# Phonu � <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) U DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> WELL# 'Z 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE /O" MULTIPLE CASINGS?0 YES XNO WELL CASING DIA: 1 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL XPVC BOTHER-- <br /> H <br /> OTHER:p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS 0 HOSE ' <br /> H AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 JYes Ig No (NATr�E: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: o' i+/ <br /> D OTHER: D OTHER APPROX.BORING DEPTH �V BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? k)r) if YES,list specifications here): <br /> 'COMMENTS: <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 OrdiRa <br /> ulations, and all applicable California State Laws. <br /> Signed x Title/Company-a V iY (r'24 /s/0-3 <br /> �r.1 'VILJ "i1CY ' L� <br /> Print Name J Date 2/ /s/0'-3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED:: <br /> Application Accepted By /�d'L��'�"—l Date Issued 6 Area 51 <br /> Grout Inspection By Date Final Inspection B) _ Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# tete <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE - PERMIT/SERVICE REQUEST# INVOICE <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 1/25/ <br />