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WE PERMIT APPLICATIONRM 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 o4 San Joaquin County Environmental Health Department <br /> WELL Location _ za Cross Street 'W �GkcL City Zip"1 5 31D�parcel#or's <br /> PROPERTY Owner Address 7 / � �_ �� <br /> C3lai�d �,(�' � city 1t't�l/lt-���ipl��hone# /� <br /> C-57 Contractor�C "ddres,_'-?ki?,2_ O tP�G��'/c City S'�-SLI,7 7��ahone#7`� 6��7��'r�64 <br /> Consultant/Sub Cntr A61!5 Address03 ? 5110' x City 9_1k_�ic# — Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WO K TO BE PERFORMED: <br /> ,ZNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') U DESTRUCTION(choose type below) I <br /> 0 SOIL BORING# 0 OVER-BORE <br /> ,a-OELL# 0 PRESSURE GROUT <br /> `Other. Grout Specifications: <br /> COMMENTS <br /> I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ;KONITORING ;111OLLOW STEM DIA.OF BOREHOLE ULTIPLE CASINGS?0 MULTI-LEVEL?WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Al*- TYPE OF CASING: 0 STEEL,,0'�VC 0 OTHER: s <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL/5-2,o Pigi TREMIE TYPE TO BE USED: 4r<UGERS a HOSE <br /> AIR SPARGE/Ozone p PUSH POINT GROUT SEAL PUMPED: des []No OT MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: OTHER APPROX,BORING DEPTH 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. j <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 Regulations, and all applicable California St to La s. <br /> x <br /> Signed �"' [.v _ -Title/Company <br /> 9 _ _ <br /> Print Name GYI /�Lrw- - Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: b / e-8 <br /> WORK PLAN DATED: -D r7 r <br /> Application Accepted By Date Issued /0// / Z Are Z-Or b S <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#— REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> II C-57 WC_-WAIVER C-57 Letter of Authorization to Sign permit Encroachment doc 8/29/02 <br />