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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 /> / Assessor's'/ / <br /> WELL Location b W 7 ��kF�� Cross�-Strtreeeet AC l/II�L CityST�kl>'l Zip Parcel# /Y 7-071 <br /> PROPERTY Owner_ ( 5_r '/L T/c+k�Address l f'(�?_ C L� CitySZoL,Lj� Zip Phone# <br /> C-57 Contractor M r7-6 1 LUA(/fndress$3L[7 S. WATY 64.City SAC Zip Lic#67LG/7 Phone ,/�l 631"3� a2 <br /> Consultant/Sub Cntr P if- Address 937 4 S��w City ?1/_ ' Lic#60Q) 21?J Phone# KL 7 l'U <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS (� <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLEZ1' MULTIPLE CASINGS?0 MULTI-LEVEL?0 WELL CASING DIA: 2 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNES$� q0 TYPE OF CASING: 0 STEEL 'PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL VfL&i t S TREMIE TYPE TO BE USED: &AUGERS 0 HOSE — <br /> 0 AIR SPARGE/Ozone 0 PUSH POINT GROUT SEAL PUMPED: Yes 0 No, -(N- /OTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: PsQ.rLAJp Z"c�PE 7- <br /> 222 OTHER:_0 OTHER APPROX.BORING DEPTH S f' 76 / B LTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDU OR CASING PROPOS�D? �0 (if YES, list specifications h e): <br /> 'COMMENTS: &t.✓-(`''//f W- (S <br /> ? ..t.AJ _ <br /> 1&t6 ^*tit < <br /> NOTr._ OFFSI E BORINGS R QUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby certify that I have prepar9d this application and that the work will be done in accordance with San Joaquin <br /> County O nces,Aules nd u ions, and all applicable California State Laws. <br /> Signed x Q / Title/Company / [ ��✓ �Q� <br /> Tint Name � t �J, �,17S,1 V Date / �� <br /> DEPARTMENT USE ONLY <br /> " <br /> SITE MAP IN UNIT IV FILE, ADDRESS: ")o r�_ , 4 <br /> WORK PLAN DATED: pct _ <br /> Application Accepted By Date Issued Area <br /> 3rout Inspection By Date VCY IF nal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS:t_14 , / r <br /> �r <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC;p BT DATE PERMIT/SERVICE REQUEST# INVOICE <br /> IMP <br /> C-57 WC -WAIVER_ C-57 Letter of Autho i4K' n Psign per it Encroachment doc 8/29/02 <br />