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LI)C-3 �vu <br /> WELL PERMIT APPLICATION FORM SITE <br /> Vq" <br /> wSAN JOAQUIN COUNTY MITIGATION <br /> Tf <br /> � ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> d,p <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 /> ..LL t 1 / Assessor's <br /> WELL Location 0 CA4'1-- l�m ,�+1(Q,et Cross Street City 7 Zip Parcel#1S1—E'b/O�-bZ <br /> PROPERTY Ownert'rLtctCY96 er--i2t � Address r City',&f Zip Phone#CO STC <br /> o e Ci A��� h Zi 1 ,f``'Lic#Phone# � 00 <br /> C-5T Contracto r� t g ddress�`Al�� � b!add�Ll3G� F.��2 <br /> Consultant/Sub Cntr�hbOk Iflro�m 10(11-.Mddress w ity��Lic# 53 Phone# l(�gi4'Z��o <br /> GIS Coordinates:X Y Township 1 N Range Section -� <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION(choose type below) <br /> SOIL BORING# f0 OVER-BORE <br /> 'WELL# (A)— l a PRESSURE GROUT <br /> `Other: / ` Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS pt <br /> bT_MONITORING 15 -HOLLOW STEM DIA.OF BOREHOLE S MULTIPLE CASINGS?0 MULTI-LEVEL?0 WELL CASING DIA: e2 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCIt qV TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:. KILIGERS 0 HOSE <br /> 0 AIR SPARGE/ozone 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes `&No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: hear Ce"41-v+ <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> "COMMENTS: <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 ave prepared this application and that the work will be done in accordance with San Joaquin <br /> Coanty Ordinan , es and Regulations, and all applicable California State Laws _ C <br /> Signed x Title/Company Z94;4;7�'�` � 7� <br /> Print Name y t��-K• Date <br /> R��TMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3`�`y`o �• -��- �'.� �� - <br /> WORK PLAN DATED: /Z'72ZO <br /> � <br /> Application Accepted By. Date Issued Area O(W,r'�"7 <br /> Grout Inspection By Date Final Inspection By to 6 �O <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RE 'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 V WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc iV 8/29/02 <br />