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WELL PERMIT APPLICATION FORM <br /> IV SITE <br /> r ,� SAN JOAQUIN COUNTY <br /> 4 MITIGATION <br /> `on. ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ,��: 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> �c ✓76 / (209) 468-3449 <br /> S <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 /> Assessors <br /> WELL <br /> WELL Location?��a�f S� v 9 / Cross Street fta w ow City 15)r-4- -Zip�C —Parcel# /1y ��• /,2 <br /> PROPERTY Owner/9N Ile NS/i Y Address U / S &fi;,�j`'� Cityy STII ZIP- hone# ^ <br /> Af'iLi =Lic# <br /> WLic#�eo2�3SPhone# g« y� <br /> C-57 Contractor /r u Address,9� � 4 3% sT' Cit)64 '� <br /> Consultant/Sub Contractor,-o.•A6,2 e 4�l!/Addressdc�31 1/d wd^�►ri�City Phone# 6t9,"- Q-s <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> AEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> �WOIL BORING# 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: 7 /0 QPo fro 6c derkSS ?� t� 5� T' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 2 MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS— IA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Z62--SC/Yle TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGEPUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: GG 1'2-55 G .vr e�ri <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH_ S 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> / Q CONDUCTOR CASING PROPOSED? V.4 (if YES,list specifications here): <br /> 'COMMENTS: S P� G y ®( t�JAO`r- <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, Rul s and Regulations, and all applicable California State Laws. <br /> Signed x ��­& Title/Company e"' o le 5; /- <br /> Print <br /> vPrint Name 1 t"�/e G r� Date <br /> DEPARTMENT USE ONLY <br /> � / r/ <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Y <br /> WORK PLAN DATED: 1 .-f ( <br /> Application Accepted By ` Date Issued Area_ <br /> Grout Inspection By 1 Date 31-t M' Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# Cer <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> F7 RRO <br /> C-57 W(;_-WAIVER— C-57 Letter of Authorization to sign permit Encroachment doc_ 1/25/02 <br />