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i <br /> WELL PERMIT APPLICATION FORM SITE <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 application is made in compliance with San <br /> Joaquin County Development Tide,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department.�sessor s <br /> 9 WELL Location /J 4 Cross Street iy Zip -f Parcel# <br /> PROPERTY Owner L�Ka �+'4 Address 877' � 7 1 City Zip�JdD lhone# <br /> C-57 Contractor IkX146 dl Address CityZip. Lic4�Phone# <br /> Consultant/Sub Cntr� ddress City_A75'L& Lic# Phone# <br /> GIS Coordinates:X ,Y Township Range_ Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION(choose type below) <br /> []SOIL BORING# VER-BORE <br /> []WELL# PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 MULTI-LEVEL?0 WELL CASING DIA: <br /> 0 EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS' TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS []HOSE <br /> []AIR SPARGE 1 Ozone []PUSH POINT GROUT SEAL PUMPED: 0 Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: r <br /> 0 <br /> OTHER:_0 OTHER APPROX_BORING DEPTH []-BOLTED TRAFFIC BOX or Il STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? ((if YES,list specifications here): <br /> `COMMENTS: 4/67,f- -Z J,. <br /> -/ot r r <br /> NOTE: OFFSITE BORINGS REWIRE 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 OrsIxces, Voiles ao Regulati ns, and all applicable California State Laws. <br /> Signed x p Title/Company • IF, ' <br /> Print Name ��r L� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> APP P <br /> Application Accepted B Y Date Issued Vr C F� 200 <br /> Grout Inspection By Date Final Inspection By �} a�_ -5 Dat <br /> Destruction Inspection By Date It <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT-REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> I IVQ ItZI32-1 <br /> C-57 WC -WAIVER '' C-57 Letter of Autho zdtit sign permit Encroachment doc_ 8/29/02 <br />