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RftLL PERMIT APPLICATION FORM SITE <br /> I14U�� <br /> SAN JOAQUIN COUNTY MITIGATION <br /> MAR Q 200f-NVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENV 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PEFRM NjrlS ] (209) 468-3449 <br /> RV CES rH 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 mate in com�fance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin county Environmental Health Department. 0��� <br /> � •/ Assessors <br /> l WELL Location �' �"-ross Street 4✓1 S city Zip Lt ParCe�!j# <br /> PROPERTY P _{�[ 7'7q7 City �6 �1zipq5�Phone# `""'y ` �S <br /> Owner Address ! _ <br /> `��/ ,�' gS�Jac# 6?1 hone#4llo Co31 35✓.3 <br /> C-57 Contractor lJf✓ ^//►t�+� dress /�1 Cl/ y_� c �Zip1 r'! <br /> Consultant!Sub Cntr. <br /> (�� Address �' `� COCity <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> C1 NEW WELL I BORING (CPT,GEO PROBE,HYDROPUNCH,HAND-AUGER,OTHER') ,gf'ESTRUCTION (choose type below <br /> a SOIL BORING# -OVER-BORE. DIAMETER <br /> o WELL# ESSURE GROUT <br /> 1 <br /> -Oth 1� C�'M GROUT SPECIFICATIONS <br /> S <br /> p <br /> COMMENTS: ill 441 <br /> GrL.c. 4.cJ•_ jAt>� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS -7 / <br /> �INONITORING ;'HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASENGS ULTE-LEVEL WELL CASING DIA: n�,+� <br /> p EXTRACTION AIR HAMMERIDRIVE N CASING THIGKNESS o` y TYPE OF CASING: []STEEL VVC p OTHER: <br /> 13 _ , <br /> �GAPOR n MUD ROTARY DEPTH OF GROUT SEAL D (`— PREMIE TYPE TO BE USED: ,'AUGERS 0 HOSE <br /> IR SPARGE!OZONE []PUSH POINT(GP or CPT)GROUT SEAL PUMPED: $'Yes a No ()NOTE: AXIMUM FREE-FALL DEPTH IS 30') <br /> 1*1 U SOIL BORING HAND AUGER GROUT SPECIFICATIONS '0 -T !�� <br /> p OTHER:_0 OTHER APPROX.BORING DEPTH�v ' Q BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTO CASING PROPCSED .(if YES,list specifications in comment sectiorn) <br /> COMMENTS: <br /> be y� V-011S - <br /> NOTE, OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONJS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with Sari Joaquin <br /> County.Oprd�i�naannyyc�es,�Rules and Regulations, <br /> and all applicable California State Laws. <br /> Signed W <br /> Print Name. >'L� ''y—' + l !�_ Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: n <br /> Application Accepted By ak"73-eel Date Issued 3II�p Area <br /> Grout Inspection By Date I 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 PERMITIS ERVICE REQUEST# INVOICE <br /> �;� ,2�� � oil SR#0� S <br /> C-57— WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />