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WELL PERMIT APPLICATION FORM SITE <br /> • Q,� MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> e0�1 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <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.Assessor's ,�-3,` <br /> I'Z Cross Street �s cn c City 1_O 47 1 Zip q.;;,"to Parcel# O�'S: T <br /> WELL Location � . �'� gl�8 <br /> PROPERTY Owner ra jt <br /> �.✓ .v�G r`1 Address InA t-' fJ wy i'Z. City(AO f Zip�Phone#('L 6,' <br /> (4S �ae��s r�+,C Address(QKC1 S1 ST 44 City L�� Zi DiagOLic#7gcgllPhone# S - 2Zg� <br /> C-57 Contractor_ �— <br /> Address 94ci SI �'I/ 0 —CityVt S Lic# � � Phone# S�v 7j �-2��� <br /> Consultant/Sub Contractor /'tS� rNC / <br /> ,Township T tL N Range V 7�._—Section <br /> GIS Coordinates:X Y 3 <br /> WORK TO BE PERFORMED: 0 DESTRUCTION(choose type below) <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER*) 0 OVER-BORE <br /> SOIL BORING# 0 PRESSURE GROUT <br /> [] <br /> WELL# <br /> Grout Specifications: <br /> *Other: <br /> COMMENTS: <br /> sl <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ES �( <br /> ONITORING 0 HOLLOW STEM DIA.OF BOREHOLE .5 O MULTIPLE TYPE OF CASING 0 STEEL OUACLLO THER:ASING Z <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS t TREMIE TYPE TO BE USED: []AUGERS R40SE <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes o (NOTE: MAXIMUM F13EE-FALL-- PTH 30'� <br /> 0 SOIL BORING []I(-IAND AUGER GROUTBORING DEPTH O T e, �Ll BO� RTRAFFIC/ BOX or MOVE PIPE <br /> 0 OTHER:_O OTHER APPROX. <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 ce - y that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County din nc s, Rul s d Regulations, and all applicable California State Laws. S� ��� <br /> Title/Company. PRrNu P4 Lt <br /> Signed x t� <br /> Date <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Date Issued�� wZ Area f <br /> Application Accepted By ^ Date <br /> Date 2 drt Final Inspection By <br /> Grout Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# GA(-4f <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 8�- 85" 572 117k yl� �v SRS 00 �1 <br /> ermit Encroachment doc1/25/0 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign p _ <br />