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WELD. PERMIT APPLICATION FURM 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 /> k71� 1i �L�� A Assessors 2OD� <br /> WELL Location _ - _ r Je Cross Street .�1 n �C'r A 'ity .lTdG�RJ/S�Zip /.� /J <br /> ' ' -- Parcel# <br /> // Inf. _ NI U <br /> PROPERTY Owner�T�O�s7T.LdC,�Dry Address �ARtG/7/`�t N S�City Sltr.�18� Zip 1�ZoZPhone# 7.881 <br /> //��� � e">' <br /> C-57ContractorZ/'treJ�iA�Address 3632 drr/f.G Cfit city !ice✓ylzip_r"'J ic# 7/7S/dphone# u�6 <br /> 250.48 !/GKl��iiwicAddress A".''¢fool Ld/lsfd T6 <br /> Consultant/Sub Cntr �/J/l+d�lifff�I� Ciry CO ✓ Lie# Phone# <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# <br /> []WELL#�/, �f —/ Tiyr/ZOG/ ,[�pE— 0 PRER-BORE. DIAMETER <br /> �� 7 []PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE <br /> 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ..s' Sia .7PE OF CASING: 0 STEEL APVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL � TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> I]AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes kNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> []SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS x/tT LJ1ylf�i5/T <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH &0 <br /> a BOLTED TRAFFIC BOX or XSTOVE PIPE <br /> CONDUCTOR CASING PROPOSED D (if YES,list specifications in comment section) <br /> COMMENTS: Gt�L ryvow —4--o <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR 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 Ordinances, R *s and R gulla�ttions, and all applicable California State Laws. <br /> Signed x /+ �'/ /'�C Title/Company <br /> Print Name C/ / �Y'��/ Date <br /> DEPARTMENT LISE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: /I+ ry 9� <br /> Application Accepted By Date Issued /VL�i `^�a�rea <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 61 <br /> C-57_ WC--WAIVER— C-57 Letter of Author zat on o sign permit_ Encroachment doc_ 9/30/02 <br /> �_ <br />