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. +w. <br /> FILE-M <br /> WELL PERMIT APPLICATION FORM SITE <br /> - : MITIGATION <br /> P SAN JOAQUIN COUNTY UNIT IV <br /> . ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-34490M i <br /> i. <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED with <br /> the work described. This application is <br /> San <br /> Application is hereby made to San,Chapter <br /> 9 1115.3 and thefor a kto construct and/or Sta dards of San Joaquin County Environmental Health Department.Assessor's <br /> in ssor's 1 z3 9!a/ <br /> Joaquin County Development Title/,�Chap Assessors <br /> �o Crxd! C.+ �► �rr�a Parcel#_ <br /> Ira Cross Street !'oh City �4 Zip ,—� 3 <br /> WELL Locatlon // ` / p l�{[!f/2�/ <br /> yy��yy� /jay SQiJI'IJM Address 633 �• n4r City Si��i Zip Q '�� Phone# Z 9 <br /> PROPERTY Owner_X ---� <br /> City S��"l'-'Ltp �!�ic#!F,�Phone#15 44CS- 8'7/2- <br /> ��jw <br /> C-5T Contractor Addres1 3 Phone#3:70o�6-r3a6 <br /> s l3�E I�,rex; CitySIW+Cic# <br /> Consultant/ 6� Section <br /> W/.U�/S/•3Q ,Y &17?sjr' 0 Tovrnship. I —Range <br /> GIS Coordinates:X " <br /> WORK TO Be PERFORMED: k Xb]ESTRUCT'ON(choose type below) <br /> IEW WELL t BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) �, MOVER-BORE <br /> `_ SOIL BORIN # 2 ` L Z Z []PRESSU13GROUT <br /> WELL# z GrautSpecifications: <br /> *Other: r cosi a <br /> COMMENTS: i7?Lt!1 C'f' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS � <br /> MONITORING OLLOW STEM �� <br /> DIA.OF BOREHOLE$rte_MULTIPLE CASINGS?1]YES )(NOWELL CASING DIA: rah <br /> Q EXTRACTION 0 AIR HAMMERIDRIVEN CASING THIGKNESS ft./J 1I� <br /> TYPE OF CASING: Q STEEL �VC (7 OTHER: <br /> Q VAPOR MUD ROTARY <br /> DEPTH OF GROUT SEAL REM1E TYPE TO BE USED: d AUGERS )jFiOSE <br /> q AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: Yes 17 No (NOTE. MAXIMUM FREE-FALL DEPTH l5 30' <br /> - -e <br /> GROUT SPECIFICATIONS: y��f�a .�f` S 0/0 �V"' <br /> "''� <br /> SOIL BORING Q HAND AUGER <br /> Q �m -0OLTED TRAFFIC BOX or 4 STOVE PIPE <br /> OTHER APPROX.BORING DEPTH <br /> II OTHER:_ � [] CONDUCTOR CASING PROPOSED?�_(if YES,list specifications here). <br /> G�f .fie+! 4` W4 SlcWA Xre -�4, /I- <br /> Pz rr° x! t <br /> •COMMENTS: 2, e t : G-I�+ttl '^ �'~ c <br /> 11114, Z L III; I <br /> NOTE: OFFSITE BORINGS REQUIRE ACCEAS SON ENCRCE OAALL CHMENT <br /> RED INS E TLONS. <br /> CALL THE UNIT IV INSPECTOR Aa WORKING HOURS IN <br /> I hereby certify that-1 have prepared this application and that the work will be done in accordance with.San Joaquin <br /> Ies and Regulations, and all applicable California State Laws. <br /> County Ordi nc O uiOr " ` 1,.er1 <br /> Tide/Company `~ <br /> Signed Date 2�<8'a2 <br /> G /_ <br /> Print Name DEPARTMENT USE ONLY <br /> ��� C <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> +O'L <br /> WORK PLAN DATED: �� — IM <br /> Date Issued A <br /> -3/—d v Area <br /> Application Accepted By Date Final Inspection Date <br /> Gout Inspection By Date <br /> Destruction inspection By <br /> COMMENTS l CONDrrIONS: - <br /> ACCOUN'TINGONLY. AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY ATI=I PERMIT f SERVICE <br /> tiv REQUEST# INVOICE <br /> �,,, / / 11! SRS Zr� <br /> ,K � 1/25/c <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc <br />