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WELL rJERMIT APPLICATION F•RM 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 I 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 /> G Assessor's <br /> WELL Location 5404.�Ar•' i a� Cross Street i--r R?i(AP hi City 5kc�6 f1 Zip SXO,Parcel# 132:228'-Ol, <br /> PROPERTYOwnerr , ryM\11 Addresslb30� I�CltNS kl 00 CityV IA U}Cre(? Zip 67Phone# 9q/57---6-;2(0g <br /> C-57 Contractor MI ,t ! Address AZT 5 bxawCitySeC n Zip4SZl9 uc#(&L=Phone#- ky=LQOlp <br /> Consultant/Sub Contractor l9� Address 837 ShAza VA'tcityS(Ce-k-kn Lic#4qa2ZZPhone# AbI-'/Jnr <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> KNEW WELL/BORING(CPT,GEOPROBE,HYDROP NCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# CI nAF , B OVER-BORE <br /> WELL# Il PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> C, IONITORING o HOLLOW STEM DIA.OF BOREHOLE_22 MULTIPLE CASINGS?0 YES O,NO WELL CASING DIA:_ '.fr <br /> 0 EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESS 1 TYPE OF CASING: O STEEL 0 PVC BOTHER: /)%M- <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 4-A^6'v2 TREMIE TYPE TO BE USED: H AUGERS 0 HOSE <br /> a AIR SPARGE RUSH POINT GROUT SEAL PUMPED: n Yes B No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: (h„`I`{0tn p <br /> OTHER:_B OTHER APPROX.BORING DEPTH 20/ 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? NIA _(if YES,list specifications 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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County <br /> yOrdinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x 1\- �� X n.�X._^ Tfle/Company caes2LG I f, F <br /> Print Name 1-�)o,r t e h0. t,'C' c� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: S` O L�n� 0 <br /> WORK PLAN DATED: cc,Z <br /> Application Accepted By Date Issued '� D` Area �/ � <br /> Grout Inspection By ^ Date O Final Inspection By Lfne n�cv. Date` <br /> Destruction Inspection By Date (( <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# tete <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ 1/25/02 <br />