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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 /> 28700 0wrjsman QOoPK I&S" Assessor's <br /> WELLLocation Dd1C--Trncvr e�,Lj Cross Stree[ SA-r �l <br /> City ' rca �9Zip,,,,,-7, <br /> QS 3'7b Parcel# a��07b—oZ <br /> PROPERTYOwner OLA ICr Tva�c� Address a56dC7 CS�csmaol2 ct, City_q,Tr � ip4 37(,Phone# ILq:. 3`I-40BL <br /> C-57Contractor Gr�W,c� tT�7+"Tes+"'�'Address CI SU tAm%ze Rm.d, City0—a&r,; Zip e145 'c# 25 jL5_Phone#_9a c 3i a—Stp a <br /> Consultant/Sub Contractor l)25 (CnnpQ<a7jsj Address 12'70 Ga. eN doks City SLU'atiALic# Phone#g16,L'7k-2Cd0 <br /> -IDr.J Su Ac <br /> GIS Coordinates:X .Y .Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) WfESTRUCTION(choose type below) <br /> D SOIL BORING# D OVER-BORE <br /> D WELL# p.PRESSURE GROUT <br /> *Other: Grout Specifications:"fyl LTlpar*1 u)jSt6s berHon4G+- Tg4ttons /yam <br /> COMMENTS: Pkieo,Se See Ont occe <br /> L (A <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING D HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?DYES ONO WELL CASING DIA:_ <br /> tirCTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL 0 PVC 0 OTHER: c <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 0 HOSE ` <br /> a AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: .D Yes ONO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (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 Ordinances, Rules nd/R/egulations, and all applicable California <br /> DState <br /> —Laws. <br /> Signed x tom' Title/Company PF-s'�e c-T /tMGL`7Z X R S co'</0' <br /> Print Name C V C Date 3- 22 - o <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED:: /y'.L <br /> Application Accepted By 44 " Date Issuedy//�/�i2' Area�'/UIeUTAC/� <br /> Grout Inspection By Date Final Inspection By "/ (yi aDatae Y 4 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# - cerx <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �T07— 3/S <br /> PO ` fit ' S4°/36 e4A- / o— SRO 00Z—"'? <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to Sign permit_Encroachment doc_ 1/25/02 <br />