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Y <br /> d WELLYERMIT APPLICATION F��RMT <br /> SI E <br /> SAN JOAQUIN COUNTY R�ITIGATIQN <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 applicator,is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and <br /> �the <br /> lStandards of San Joaquin County Environmental Health Department. <br /> 14.41s�S±�/� AAssessor's/ <br /> WELL Location 1 V J� Cross Street /NY City I�h,/ Zip —Parce[# <br /> PROPERTY Owner CI $f Address N �c�City '+a'Il Zipf F i Phone#4�? iz �:YT <br /> C-57 Contractor N45MA-2, Address5Z3 3 e-(��ty� Zip9S'T 4ic# �1Phoh <br /> Consultant/Sub Cntr s 7� Addres� �City�✓t Lic# .— Phone# " 7 i <br /> GIS Coordinates:X Y Township Range Section <br /> IY98K TO BE PERFORMED: <br /> EW L 1 BORING(CPT,GEOPROBE,HYDROPUNCH,HA OTHER*) _ []DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> p WELL# 0 PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �G <br /> �VIONITORING HOLLOW STEM DIA,OF BOREHOLE !AL MULTIPLE CASINGS?0 MULTI-LEVEL?0 WELL CASING DWI? vI <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS IV,4 TYPE OF CASING: 0 STEEL 0 PVC BOTHER:_ <br /> 0 VAPOR 1]MUD ROTARY DEPTH OF GROUT SEAL 15b fl REMIE TYPE TO BE USED: a AUGERS 0 HOSE <br /> D AIR SPARGE/Ozone 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes )}-No NOT -MAXIIM'UM FREE-FALL DEPTH IS 30') <br /> L]SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: ❑OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> y� <br /> pp� CONDUCTOR CA I G PROPOSED? Al, (if YES,list specifications here): <br /> i <br /> *COMMENTS: �t '14 8 En A,kD— <br /> 'a <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 /> l— <br /> Signedx Title/Company !?�� d t �� <br /> Print Naive �� �I+ Date <br /> DEPARTMENT USE ONLY , <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> � -- . <br /> WORK PLAN DATED: <br /> Application Accepted By f ' Date Issued — Area <br /> Grout Inspection By ate Final Inspection By Dale <br /> Destruction Inspection By Date JAN 1542003 <br /> COMMENTS I CONDITIONS: Z 17A 1A) ' <br /> ACCOUNTING ONLY: A1D# <br /> PERMIT/SERVICES <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> /?9l D I Z 12 5 <br /> It C-57 WC -WAIVER C-57 Letter of Authoriza h t sign permit Encroachment doe= 8/29/02 <br />