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.wr�V <br /> i <br /> x WELL PERMIT APPLICATION FORM 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,Ch ter 9-1 t 15.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location �ul( _Cross StreetSF /�Ci Zip l� Parcel# <br /> PROPERTY f Q Gl ./ f 2 1�7 <br /> Owner [f V�l/� r /Address Phone# 0,q q�� G p <br /> C-57 Contractor)eA ' �®-Z)(-t f I/^Add res��0Y,2,y r�i� city _Zig 4ic#,7n��hone#191&630 r�tp <br /> 1 tea, I/ <br /> Consultant I Sub Cntr oqC7 C— �1 Address g ni St+i �iG City lVLic# + ?Phone#� 4&' Z <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL 1 BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER`) Q DESTRUCTION (choose type below) <br /> a SOIL BORING# 1]OVER-BORE. DIAMETER <br /> )KWELL# SU Q PRESSURE=GROUT <br /> Q*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING HOLLOW STEM DIA.OF BOREHO EI�� LTIPLE CASINGS Il MULTI-LEVEL WELL CASING DIA: <br /> IJWXTRACTION 1]AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL IeVC a OTHER: <br /> C/APOR {]MUD ROTARY DEPTH OF GROUT �L3 3O TREMIE TYPE_TO BE USED:/,Er, S 11 HOSE <br /> a AIR SPARGE)OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes p No (NOT, : MAXIMUM FREE-FALL DEPTH IS 30) <br /> Q SOIL BORING a HAND AUGER 'GROUT SPECIFICATIONS a, 1A <br /> Q OTHER: Il OTHER APPROX.BORING DEPTH 5t> Ft!2 ` RIOLTED TRAFFIC BOX or a STOVE PIPE <br /> J /CONDUCTOR GAAINC PROPOSED (if Ypp,,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances,.Reales and Regulations,and all applicable California State Laws. <br /> Signed x wJ , / Tule/Company �f• J� .. Wit_,�/ <br /> Print Name I, ! Lf� Date 2 'f <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: �7 <br /> Application Accepted By � t<V Date Issued �V Area <br /> Grout Inspection B IV V 9 Date inal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS' <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DAT PERMIT 1 SERVICE REQUEST# INVOICE <br /> NO 1 g - 00 <br /> Zoo to sR# 3 <br /> r'` C-57_ WC -WAIVER C-57 Letter of Authorization to si n permit Encroachment doc 9/30/42 <br />