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WEL&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 /> DF � �` �`�!_ Assessor's <br /> WELL Location Cross Street City C'� Zip /JZ Parcel# It 11 t7 <br /> PROPERTY Owner_ �C�� Address � >� . � City zip%5Z I Phone#p��2— "- 1�7 <br /> C-57 ContractoPI 66014 /Y� �� Address `!5" / vw_ City Zi ��ic#[6P�Fhone#/Z5 3/3 3?w <br /> Consultant/Sub Cntr + C Address �37 �Ci�Lic# Phone# q,,6 7/OD c, <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(_CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION(choose type below) <br /> SOIL BORING# 0 OVER-BORE <br /> WELL# 0 PRESSURE GROUT <br /> *Other. Grout Specifications <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING Q HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 MULTI-LEVEL?a WELL CASING DIA: <br /> EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS All — TYPE OF CASING: 0 STEEL U PVC p OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL/b0 FZ-_ —TREMIE TYPE TO BE USED: GAUGERS (I HOSE <br /> Q AIR SPARGE/Ozone)JeUSH POINT GROUT SEAL PUMPED: 'HYes p No ((NOTE: AXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 17 HAND AUGER GROUT SPECIFICATIONS: <br /> 1]OTHER:_0 OTHER APPROX.BORING DEPTH J O'b BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> n CONDUCTOR CASING PROPOSED? {if YES,list specifications here): <br /> *COMMENTS: SGS CjLYI/I a�-S <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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x W Y4— am/ Title/Company s <br /> Print Name k l/1,;%,u_ !, l Date L /� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 328 <br /> pep <br /> WORK PLAN DATED: <br /> Application Accepted Bybate G Issued 1 Area <br /> Grout Inspection By Date I 1 inal Inspection By Date <br /> Destruction Inspection B Date <br /> COMMENTS/CONDITIONS <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY I DAT PERMIT/SERVICE REQUEST# INVOICE <br /> `J 7 <br /> IP/0 oZ 3 (53 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ 8/29/02 <br />