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WELL PERMIT APPLICATION FORM SITE <br /> WE C'EffEb MITIGATION <br /> W SAN JOAQUIN COUNTY UNIT IV <br /> ITEC 2 f ?001 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENT HEALTH (209) 468-3449 <br /> DERKT'SERVICES <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 ent Title,chap r 1 1 and the Standards of San Joaquin County EnvironmenSal��D e a ST Assessor s <br /> �,�tglJ;F7L <br /> W. �5ToF VkN 3w�N ST. 4 froKTM-e1 <br /> WELL Location ^' 1 S D Cross Street City STocrTOp/ ZiPlg5203 Parcel# <br /> �/ n� =7jp4W1­ic# <br /> I Zoq-93 <br /> PROPERTY Owner lil 0 5 O Address 4'� /V' 6LDD�ZA'r�a7 5ZIP ZPhone# 3 <br /> 2$ 2-12C-57 Contractor Address Cit) f90a 3 Phone# <br /> `DPS F�I)� ' T 15 <br /> Consultant/Sub Contractcrr'eOpwey-"1��� Address 555 IUAA1 r�O CF7 3CitY SF Lic# _wPhone# <br /> GIS Coordinates:X <br /> y_,.Township Range Section <br /> WORK TO BE PERFORMED: ] ESTRUCTION(choose type below) <br /> Q NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) f OVER-BORE <br /> Q SOIL BORING# PRESSURE GROUT <br /> Q WELL# <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> Y TYPE OF WELL' I'� INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �MONITORING!'' Q HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?Q YES Q NO WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> Q <br /> OTHER:_0 OTHER APPROX.BORING DEPTH Q <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'GO9P mlztiT& <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 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina e , Ru s d Regulations, and all applicable Californian State Laws. L <br /> Title/Company `�r CZ PJ`o2yT <br /> Signed x <br /> GDate <br /> Print <br /> Print Name i / K` DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> l2 <br /> Application Accepted By Date Issued- <br /> y <br /> By <br /> Date Final Inspection By <br /> Destruction Inspection By Date <br /> A a <br /> COMMENTS/CONDITIONS: Pelt* <br /> s <br /> ACCOUNTING ONLY: "AID#PE CODES FEEINFOCHECK# R C'D BY DATE PERMrr/SERVICE REQUEST# INVOICE <br /> 29oZ `� OZ 3 SR# <br /> C-57 WC -WAIVER C-57 Letter of Author io to sign pe mit Encroachment doc 1/25/C <br />