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II_ WELL,.wERMIT APPLICATION F1_,.s-,M SITE <br /> �,M SAN JOAQUIN COUNTY MITIGATION <br /> SEP 2 ZW3 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENVIRONNicNIT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/S�-7 W0'ES (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 /> n _ Assessor's <br /> WELL Location pw5 7 5su±r\9 I N-(kdo Cross Street City �"ta ,- Am—Zip Sze Parcel#_ 5• _ 53-01 <br /> c Karan ,�1on <br /> Z013)-+ t DorU40 ,6 <br /> PROPERTY Owner— <br /> C-57 <br /> (- <br /> _ Address- City ,,� r) Z�pehone# / (??1 <br /> C-57 Contractor_ ` ✓Cc`d gin <br /> Address -/ 7 2) ��,t/�<_��O/�City�Zip��t1 Lic# ��QPhone# �t z� — <br /> Consultant/Sub Cntr� �!� Address 1�5�� CityL_� 1 Lic#(rjjd-}aj Phone# 7'f <br /> GIS Coordinates:X Y Township_ Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT, GEOPROBE,HYDROPUNCH, HANG-AUGER. OTHER') Q DESTRUCTION (choose type below) <br /> `SOIL BORING#_ __ Q OVER-BORE <br /> WELL# `� Q PRESSURE GROUT <br /> 'Other: _Grout Specifications: 'QOtj I&-yJ l�l!vt <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING Q HOLLOW STEM DIA.OF BOREHOLES MULTIPLE CASINGS? Q MULTI-LEVEL?)(WELL CASING DIA:___ <br /> Q EXTRACTION Q AIR HAMME.R/DRIVEN CASING THICKNESS_ TYPE qF CASING: Q STEELVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL C_�1 a IREMIE TYPE_TO BE U?EDT: Q AUGERS Q HOSE <br /> Q AIR SPARGE/Ozone Q PUSH POINT GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />*SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: E�tif� _fit ce jy�&� <br /> Q OTHER: ❑OTHER APPROX.BORING DEPTH �I ' �OLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> `COMMENTS: � v� 4 l I 1 <br /> •Z. " oZ12 <br /> NOTE: O SITE 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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Re ulations, and all applicable California`State Laws. <br /> Signed x N- _Title/Company__ <br /> Print Name_ E'x To r Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> 1 r <br /> Application Accepted By 1. Date Issued AKY, ZWJ Area <br /> Grout Inspection By _Date Z I _Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDMONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC-D Bf DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authors otlon sign permit Encroachment doc 8/29/02 <br /> t: <br />