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WELL PERMIT APPLICATION FORM SITE <br /> EDD <br /> MITIGATION <br /> -SAN J,QAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL'iHEALTH DEPARTMENT (EHD) <br /> SF? 2001 E. V"ber,1hiird Floor, Stockton, CA., 95202 <br /> p rt r (209)468.3449 <br /> s'rlY HCJ"LIH <br /> FtON-REFUNDABLE PERMIT�XPIRES 1 YEAR FROM DATE ISSUED. <br /> Appllcatl�igr f r,F�i, oaquin County for a permlt4o wdn truct and/or install the work described. This application is made in compliance with San <br /> Joaquin ty'Dev lopment Title,Chapter <br /> S T 5tandaids of San Joaquin County Environmental Health Department. <br /> A <br /> ssessor <br /> WELL Location rCd /: ssiStreet s <br /> � City�.I��Zip Parcel# ��"'�z00Zi <br /> i <br /> PROPERTY Owner Ownerr"'rf " /�t� '' Address -'i"s � I <br /> mJ Ph'o-ne#! Z_ q_ - 9464 6,20)-' <br /> C•57 Contractor GLe,, 4- Address r-Iv Cfty Z!p gL6Gic# I!LL_ Phone# K-L" -D <br /> } <br /> Consultant I Sub Contractor 4-0-^z _�Address CityLic# Phone# . <br /> GIs Coordinates:X Y ;Township Range Section <br /> WORK TO BE PERFORMED: + <br /> a NEW WELL I BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") )KOESTRUCTtON(choose type below) <br /> 0 SOIL BORING# a OVER-BORE <br /> a WELL# ,(PRESSURE GROUT <br /> 'Other: ' Grout Specifications:AAd &11I <br /> COMMENTS: 7N Pi1a 2 € <br /> s I;I <br /> TYPE OF WELL INSTALLATION TYPE_ CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA.OF 80REHOLE MULTIPLE CASINGS?DYES 2140 WELL CASING DIA: <br /> 0 EXTRACTION 11 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC a OTHER: <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> 0 AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: D Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING D HAND AUGER GROUT SPECIFICATIONS; <br /> 0 OTHER._Q OTHER APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or ,, STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? r if YFQ Net 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 appliaatlon,and that the work will be done in accordance with San J6aquin <br /> County Ordinances,Rules and Regulations;.and aft applicable California State Laws, <br /> Signed x� .� !v. _ _• TillelCompany ` r✓ I <br /> Print Name /za Date D r' f <br /> DEPARTMENT USE ONLY <br /> om►• <br /> SITE MAP IN UNIT IV FILE,ADDRESS:C <br /> WORK PLAN DATED: u D 10107 <br /> Application Accepted ByaAniaa Date Issued 1V O7 Area <br /> Grout Inspection By Date 10, OT Ffnal Inspection By 1-j_k1- .e:P Date/0 9/—,o <br /> Destruction Impegbon By Dale <br /> COMMENTS/CONDITIONS-.__L_17 f 5Lh L(Sf'': IIIIi std .Je <br /> FIICOUNTING ONLY; AID <br /> rnrn <br /> CODESFrEE INFO AMOUNTREMITTED CHECK# REC'D BY DATE PERMITI SERVICE REQUEST# INVOICE <br /> 6L 60' 6d 5R# DS7�8S <br /> C-57 WC -WASVFR__ C-57 Lefter'of Authorization to sign perrnit_Encroachment doe_,,,,_. : 1/25/02 <br /> i <br /> t <br />