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CD <br /> WELL PERMIT APPLICATION FORM � <br /> 40 ? - SAN JOAQUIN COUNTY MITIGATION <br /> P UNIT IV <br /> t <br /> v U_ ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 0/j <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicabon 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 Assessor's 12.7 19/n/ <br /> WELL Location � �y, Cross 5treei ARAM C'tyS�` '4^ Zp s� Parol# x••64 <br /> PROPERTY Owner eZ Addressl63? 4ei. �pArl- Crty Al_c4r� Zip A0 Phone# 209 4CF42f, <br /> C-57 Contractor h/ C dress 6s 1 City S �'�'rZlp��c#S/L Phone#_gg <br /> Consultant/� <br /> t 1 ! Address t•��EI,,pp <br /> Mrgx !l_Cr 4 rc#Sl 3r J7Phone#f� <br /> GIS Coordinates XWIJLl�l4'•�9 '.Y iV ffgr- OW",Township /V Range--!9-19 Section 44 <br /> WORK TO BE PERFORMED, ' ]ESTRUCTION{choose type below) <br /> �1EW WELL I BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) �� MOVER-BORE <br /> I]501E BORING# <br /> WELL L -a 17 �¢ � � gpr GROUT <br /> *Other Grout Specifications <br /> COMMENTS MW/ <br /> TYPE gF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING XHOLLOW STEM DIA.OF BOREHOLE g,*:S, MULTIPLE CASINGS?[I YES X10 WELL CASING DIP. <br /> EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS TYPE Or-CASING uSTEEL VC Q OTHER <br /> VAPOR []MUD ROTARY DEPTH OF GROUT SEAL Le REMIE TYPE TO BE USED a AUGERS NOSE <br /> G AIR SPARGE PUSH POINT GROUT SEAL PUMPED JUYes []No (NOTE• MAXIMUM FREE-FALL DEPTH 15 30'; <br /> [I SOIL BORING HAND AUGER GROUT SPECIFICATIONS0ro An -'4 <br /> 11 OTHER []OTHER APPROX.BORING DEPTH O++* 10OLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?. -10 (if YES,list specifications here) <br /> *COMMENTS 0'/'�Z •Z� ra&AI j%WAy ArA%e-; 40"4 f Xa+( 4U*j >�A er .lam, /2- r-4.1- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT 1V INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi nc les and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company_ <br /> Print Name � � � _Date <br /> DEPARTMENT USE ONLY Date <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ��fl.�/� I' "-"-' <br /> WORK PLAN DATED: �� r '�� <br /> Date Issued Area_,,, <br /> Application AccepteLBy_7 <br /> �Z Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Des7uctlon Inspection BY Date <br /> 0 - <br /> COMMENTS ICON DITIONS <br /> MC-577�� <br /> LY AID# rarer <br /> E INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> � gp, 5 / - sR �� <br /> -WAIVER C-57 Letter of Authorization#o sign perlrnit�/Encroachment doc 1/25/( <br />