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WELIkERMIT APPLICATION F%.ORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EH,D) 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 r i e iE,o m n <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Depart <br /> . <br /> //-- q Assessors <br /> WELL Location ��� C� �� CA c-20 Cross Street City S�'c-��vr, Zip C),KZ O Z Parcel# <br /> PROPERTY 1r <br /> Ownerlln i-F�rs 1 �r d_ Address;X#41 &) (ICOJ ID _City 5 Apj4an Zip-)S-ZQZ Phone# <br /> C-57Contractor �; r l�" j n c . Address 21 r'7 S L a City �,lf Zip `7°)frLic#7�g`�Phone# -7 2 Z$t/ <br /> Consultant/Sub CntrF—E C AddressS"/ fair Cccn Ter- City Lic# Phone# 7 d 62-e 3 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT, EOPROB HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> SOIL BORING#��i 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> OTHER: G >­�o— 0 OTHER_ APPROX.BORING DEPTH 10 t- &1 AA 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <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, Rules and R ulations, and all applicable California State Laws. J <br /> x Title/Company <br /> Signed <br /> Print Name /L�,h /�� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: B —T Q S� e <br /> WORK PLAN DATED' <br /> Application Accepted By <br /> Date Issued �(� f' 3-U Area t/P <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# RFAC#PE CODES FEEINFO AMOUNT REMITTED CHECK# ATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57 WC ✓ -WAIVER__ C-57 Letter of Authorization to sign permit Encroachment doc 9/30/02 <br />