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FILE <br /> WELL P-P-kMIT APPLICATION FORM SITE FY <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <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 applications 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 /> �� �y�I ' G� �,.��� Assessor's, _ <br /> WELL Location //D N• �`ice, r�1� ot-oss Street •Ll2i ftC4` City !S L�� zip Parcel# �I.�n� �p -.',�G�fl <br /> PROPERTY Owner 6hct rtill r,✓ Address 3�/"�i 7 CnF�llC$�✓�'f City �����ZIP Phone#,;??-5 v 'Z—/T-2' <br /> C-57 Contractor Addrass�5 1 `J}'liC.u; X c Ciiy jlY, r ZIP1�u..�Lid1 r' r3 Phone#�.�;-L 7-[C-%I <br /> Consultant/Sub Cntr f'T V`' Address -] Sb �City­_I;kj�r _Lic#/ �'x>-� Phone# <br /> n <br /> GIS Coordinates:X ^Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> g NEW WELL J'BORINQ,(C ,GEOPRR B ,HYDROPUNCH,HAND-AUGER,OTHER- p DESTRUCTION(choose type below) <br /> �- ORING# a OVER-BORE <br /> WELL# / 1 RESSURE GROUT <br /> r +r r� Wil. Grout S ecifications: �l`r t rn yj I L r re--T) 11 <br /> 'Other: +S - 1 ' P ..�=s�� <br /> COMMENTS J <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS /�f <br /> a MONITORING o HOLLOW STEM DIA.OF BOREHOLE . MULTIPLE CASINGS?11 MULTI-LEVEL?p WELL CASING DIAL 4/ - <br /> U EXTRACTION Il AIR HAMMERIDRIVEN CASING THICKNESS fVi TYPE OF CASING: n STEEL 0 PVC 0 OTHER: <br /> a VAPOR ��aa MUD ROTARY DEPTH OF GROUT SEAL k', G TREMIE TYPE TO BE USED: AUGERS p HOSE <br /> U AIR SPARGE/Ozone 74 PUSH POINT GROUT SEAL PUMPED: Q Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> �501L BORING a HAND AUGER GROUT SPECIFICATIONS: •.Dnf',i't Y i �T�u---:Z/LL <br /> o OTHER: 0 OTHER APPROX.BORING DEPTH' I l: p BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?—7Vt) (if YES,fist sperifimtions here): <br /> 'COMMENTS: <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 /> I 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 Re ulatio s, and all applicable California State Laws. <br /> Signedx '�y < LTL Titie/Company <CA TTc�'..ttiUlkct 6�L�O IIVI(1V1�1 u <br /> Print Name t )C*u�l�, 5eXf7l(\ - Date (�— <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued `� Area <br /> Grout Inspection By Date Final Inspection Date <br /> Destruction Inspection By Date <br /> COMMENTS l CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# 'D BY I DATE PERMIT/SERVICE REQUEST# - INVOICE - <br /> 40 29'�S z3 Oda y3 <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to 549n permit_En rs oachmentdoc $/29/02 <br />