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o FILE COPY } <br /> WELL PERMIT APPLICATION FORM SITE� MITIGATION <br /> L <br /> J i SAN JOAQUIN-COUNTY UNIT IV <br /> /IRONMENTAL HEALTH DEPARTMENT (EHD) <br /> OC 12 5 95202 <br /> `3D4 E. Weber, Third Floor, Stockton, CA , * r <br /> (269) 468-3449 <br /> 0 <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 Sad <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />_ Assessor's A 2 <br /> WELL Location 2�7 D•�•-eu� 7c . I� Cross Street. 4i(fAtt City �yL Zip ParceMi <br /> PROPERTY Ow ,e��rila4l l//cf- <br /> SFoF�ax� l5 'ddress4%1�AA 'w�+se 4r1• CityZip`('�5A PhonS -950 <br /> e# SL <br /> /f 0 <br /> G-57 Contractor p'4 PtIJ/lltl•atl�CR Address a4l�&r (e Ade, Ci �r2 ZIpISS03' Li�Zk _Phone#�Q, JjjPc <br /> �� , d Il � �L fOu(p Lic#IYL�-; Phone# ( ,.7. - : <br /> Consukant l Sub CntrF10ri2ou I1/Jl ro�.ttnti-a. Address '(dB�'�'4N�City�[S� <br /> GIS Coordinates:X ,Y ,Township - Range Section <br /> WORK TO BE PERFORMED: �� I, DESTRUCTION(choose type below] �( <br /> b'1V EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) <br /> SOIL BORN # ° p OVER-BORE <br /> SIN � �� PRESSURE GROUT <br /> P`-ELL# <br /> *Other. I Grout Specifications: <br /> COMMENTS I <br /> TYPE OF WELL INSTALLATION TYPE- 'I'CONSTRUCTION SPECIFICATIONS w <br /> p4•AONITORING HOLLOW STEM DIA!OFBOREHOLE�/ MULTIPLE CASINGS?0 MULTI-LEVEL? WELL CASING DIA <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN If CASING,THICKNESS 40 TYPE OF CASING: 0 STEEL•APVC a OTHER:- <br /> a VAPOR a MUD ROTARY jf DEPTH OF GROUT SEAL !f r TREMIE TYPE TO BE USED: XAUGERS HOSE <br /> a AIR SPARGE/Ozone 0 PUSH POINT ;IIIIIIIGROUTSEAL PUMPED: 0 Yes ;ZE: MAX <br /> No (NOTIMUM FREE-FALL DEPTH IS 30') , <br /> p SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: -L <br /> p OTHER:_D OTHER APPROX.BORING DEPTH b S� �8OLTED TRAFFIC BOX or p STOVE PIPE <br /> 'CONDUCTOR CASING PROPOSED? NO (if YES,list specifications here): <br /> *COMMENTS: I �q <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 /> 1 hereby certify that I have prepared this application and that the work will be done In accordance with,San Joaquin <br /> County Ordi/.. . --e-4, Rules and Regulations, and all applicable California State Laws. . <br /> !Signed XnIf Title/Company ©d `C�'���1t <br /> V <br /> Print Name +C5ct0/ SK't'� �� DateDEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: S ILfm'.2- <br /> ) <br /> I <br /> Application Accepted By Date Issued <br /> /D-26—O Area 06 } <br /> Grout Inspection By =;ii& <br /> I� Date Final Inspectio Date <br /> Destruction Inspection By {. 111 Date <br /> IV <br /> COMMENTS/CONDITIONS: ii h I <br /> I <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE - <br /> 3501 MW ll,olo io-zs Ot"� D d y' <br /> .. _ 8/29/0 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br />