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WELL PERMIT APPLICATION FvRM 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 ophyn to construct and/or install the work described. This application e ci om i <br /> Application is hereby made to San Joaquin County for a permit <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Depart men Assessors <br /> / Cross Street City4�vc G�yh Zip 2a Z Parcel# <br /> WELL Location ,�/ <br /> PROPERTY it <br /> � ,V, , 1 i <br /> V �• �- � Address'�'ty �I �l�'�"� City J bi.��'o. Zip9 SZo2 Phone# <br /> Owner n! ;r� r o_ 7Sa P8� <br /> C-57 Contractor �'- Zi r a t <br /> Address 7GcZ S{ L�is�.��' City one# ) x <br /> <*/Sl+,l! Zip `7°2J�Lic# Ph <br /> l Phone# 7 6 62-e,3,, <br /> � <br /> Consultant/Sub CntrAddressS1'/ f k ccn�e�/ City Lic# <br /> GIS Coordinates:X <br /> Y ,Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION (choose type below) <br /> NEW WELL/BORING (CPT, EOPROB HYDROPUNCH,HAND-AUGER,OTHER`) 0 OVER-BORE. DIAMETER <br /> SOIL BORING#�(+i 0 PRESSURE GROUT <br /> 0 WELL# GROUT SPECIFICATIONS <br /> 0`Other <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 KNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> EXTRACTION D AIR HAMMER/DRIVEN CASING THIC <br /> 0 VAPOR D 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:_ � <br /> Crf-moi„ 0 OTHER (rte�1��`— APPROX.BORING DEPTH 1 c' " - r �X 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> — <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. <br /> Title/Company <br /> Signed x / <br /> Date�/— /.3—0 ?i <br /> Print Name ZJ DFPAi2TMF T USE ONLY <br /> a r(/ /U,6�-� i <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Date Issued <br /> U Area LAO <br /> Application Accepted By Date Final Inspecti �; Date <br /> Grout Inspection By <br /> - <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOLREMITTEDCHECK#EY7 <br /> REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Sao 1 �,� sR# X636021 <br /> 6D <br /> C-57 WC ✓ -WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc 9/30/0 <br />