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WELL PLIRMIT APPLICATION FORivi 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 of San Joaquin County Environmental Health Department. <br /> ,,, >� 85203 Assessors <br /> WELL Location /� � O Cross Street �V!/ City (�fi Zip Parcel# <br /> PROPERTY Owner(�K 4 L Q'� Address PO J?�1� City 'GYJ J Zip S'L/o2 Pho �2 t�S. <br /> C-57 Contractor�iagj2¢ (S�" Address 37 �5-14R a Ci p9-i?!B Lic#bFV'6�hone �9,9AZ(C� <br /> Consultant/Sub Cntr Address City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> VEW WELL/BORING(CPT,Qj�,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE.-2'-"'�nULTIPLE CASINGS?0 MULTI-LEVEL?0 WELL CASING DIAV4- <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS /vim- TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL6,- S TREMIE TYPE TO BE USED: RIAUGERS 0 HOSE <br /> 0 AIR SPARGE/Ozone <br /> ,,g'PUSH POINT GROUT SEAL PUMPED: 0 Yes LKNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,Q'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH lvS Fri- 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 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 (z f7l}��ji tick /'q C-7C <br /> Print Name 1 )4c-,— (i►"�� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Ti <br /> WORK PLAN DATED: <br /> Application Accepted G Date Issued4-12,3103 Area 5- <br /> Grout Inspection By B Date i 2 t inal Inspection By li,kirnteAa 4e�& ZbA3 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: OT Y S -Z 3 4z <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3So I 89, oo .� j got 835-78 <br /> C-57 WC -WAIVER— C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02 <br />