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WELYPERMf <br /> T 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 /> WELL Location 1 / Cross Street City S3 i4•Zip Parcel#ors <br /> PROPERTY Owner C"/J CPG (/\ Address/itrf4� e ,Qy��Clty Zipkh77hone# <br /> C-57 Contractor 'V�i iv!J � ress qq City Zip Li �hone# <br /> Consultant/Sub Gntry 47� / Address�J 7� /� City /` ,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 /> [I SOIL BORING# OVER-BORE <br /> 0 WELL# .PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS , <br /> K.MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?[]MULTI-LEVEL?0 WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREM.IE TYPE TO BE USED: 0 AUGERS` 0 HOSE <br /> []AIR SPARGE I Ozone [I PUSH POINT GROUT SEAL PUMPED: 0 Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 7� <br /> CONDUCTOR <br /> �CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS.,_/+ ��� Y� ,6 � <br /> L13j <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 ha pr red this application and that the work will be done in accordance with San Joaquin <br /> County antes, les an egulation , and all applicable California Srle4iel <br /> aws. <br /> Signed x Title/Company / <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT 1V FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By ,�,� v V 1Awl r J <br /> Date Issued Are <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> r <br /> f <br /> ACCOUNTING ONLY: AID# - <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DA PERMIT/SERVICE REQUEST# INVf' <br /> S502- .00 an o2 0Z CZ 2 <br /> C-57 WC=WAIVE=R C-57 Letter of Authortza o sign p mi# Encroachment doc r <br /> I, , <br />