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WELL'--PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <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 /> WELL Location 0 �� R lj� Cross Street �� Ci .� �' Assessor's <br /> ty �l ZipO Parcel# <br /> PROPERTYOwner S 1 C�'�COr��a r '!S Address Q1-/1,LX. City540f 6� Zip(1Sj3D(-- Phone; Z0c) )OO(D-110,31 <br /> C-57 Contractor a :GL Address p ity ip Lic# (� Phone# <br /> 5S <br /> Consultant/Sub Contractor ilk Address IZ � fc'�� City ���Lic# Phone# � t/��S -��-7 <br /> GIS Coordinates:X Y Township Range.} Section <br /> WORK TO BE PERFORMED: <br /> KNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') Q DESTRUCTION(choose type below) <br /> H SOIL BORING# H OVER-BORE <br /> HWELL# Mw -d: iTl�-� Grout Specifications: []PRESSURE GROUT <br /> 'Other: fications: �7C � �^L �C'c�r+L�'�- <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'MONITORING (]HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES D4',L0 WELL CASING DIA:,-X <br /> H EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS L(�_C TYPE OF CASING: 0 STEEL *�VC H OTHER: <br /> O VAPOR H MUD ROTARY DEPTH OF GROUT SEAL - TREMIE TYPE TO BE USED: 'AUGERS G HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: []Yes #No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: -i;LX -k" C��- <br /> OTHER: H OTHER APPROX.BORING DEPTH �� �BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? fie (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 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 State Laws. <br /> Signed x Title/Company .a e - <br /> Print Name CA JJ'2 — r-k-1 r f C Date -S-C, a <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: I -S I 1��1 U t- <br /> WORK PLAN DATED: r�t0 50 c) Z <br /> Application Accepted By -I-1.' Date Issued .� Area <br /> Grout Inspection By Date S ? ` Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> c n rr+r <br /> PE CODES FEE I FO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> a 3 3 Is �� SR# <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment oc 1/25/02 <br />