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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> FILE COPY SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E. Weber, Third Floor, Stockton, CA., 9520?3AN 2 8 <br /> (209) 468-3449 X005. <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUOQNW HSA -TH <br /> Appliption is hereby made to San Joac{uin County for a permit to construct andlorinstall the work described. Th ��iR Compliance with San <br /> Joaquin County Development Tide,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Heaith'Department. , <br /> (j Q� 1�- Assessor's <br /> WELL Locatio� -4 i �' r""� ye_ Cross Stre[ett ` �I�`�amity 5� [1:-_` 91Parcel# G1,6i 3 310 6 G <br /> PROPERTYOwner gY _ _Address 77T 7 max - -Ci44! ZipQ2�7Phone# ;�2 <br /> ti <br /> C-57 Contractd/1L d S C Q 9Pa• D A 11 Address, (3 2 0111 -�,- C iI Citty54 p �' c# hone4_1"6Q J011,6 . <br /> Consultant/Sub Cntr Addresew S tow Phone# 467 "D-D' <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> /8'N EW WELL 1 BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION(choose type below) <br /> [�SOIL BORING# [I OVER-BORE <br /> p WELL# [I PRESSURE GROUT <br /> "Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFIC MON5 ` <br /> �KAONITORING 'edHOLLOW STEM DIA.OF BOREHOLE ULTIPLE_CASINGS?[]'MULTI-LEVEL?0 WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS E OF CASING: [I STEEL_ . 'PVC a OTHER: <br /> [I VAPOR []MUD ROTARY DEPTH OF GROUT SEAL�� ` TREMIE TYPE TOLSE LfSED: eAUGERS (I HOSE <br /> c AIR SPARGE/ozone IJ PUSH:POINT GROUT SEAL PUMPED: 0 Yes [].No (NOTf.- MAX MU'M-.FRE9+ALL DEPTH-IS.30') <br /> a SOIL BORING [)HAND AUGER GROUT SPECIFICATIONS: ,0 0G[[ <br /> 1]OTHER: n OTHER APPROX.BORING DEPTH U/� r r ,F1°BOLTED TRAFFIC B®X oi []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (it YE <br /> CONDUCTOR 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/IO,,r'_dinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x W LAHiTide/Company <br /> Print Name Y+' i A a ul l±I"rLQl ^Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 2-7 . ( eir- Zob <br /> Application Accepted B L Date Issued_.F�.�JUiS Yer /O ZODEArea 1 <br /> Grout Inspection B Date / S_ Final Inspection By �T Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: X T0-V2±4 4yIIG <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> so t 89. Do 21 ? 00497 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02 <br />