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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> 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 Joaquin County <br /> Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> _ As essor's <br /> WELL Location 23Y4 " �y jt" 'J FJL Cross))Street��E;�'1�� �T City cU4 c`7 Zip Parcel# 1 3" 3 66-409/ ,/"3( <br /> PROPERTY Owner_VeQiLj tk'Vf 2y ey, Address/Z y <atn(24wu,f City(�c 7r Zip9���r Phone# ZU G7G7-'lS d <br /> C-57 ContractorAiaJ4uCt7 (w��iN✓1QAddress Q� CC�dt✓ Ccs City &1,7ur Zip�Skruc#/i4bZZ7Phone# <br /> Consultant/Sub Contractor Rn4/AwfCkPLrk V12 Address 837 �I(Ate_AoCityS'r:-'c Tv,-iLic#47 u�Phone#�Z` <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BEP ED: <br /> p D1EW WELL/ O (CPT,G PR ,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 7� IL BEORING# OVER-BORE <br /> 0 WELL# 0 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 " _MULTIPLE CASINGS?0 YES )<NO WELL CASING DIA: /��+ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSd(V TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL tJfAL TREMIE TYPE TO BE USED: ()AUGERS HOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: Xy-es p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ( 9 <br /> n <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: r �> 7�& -�// <br /> 0 OTHER: []OTHER APPROX.BORING DEPTH 3y` 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PLROPOSED? (if YES,list specifications ere): �r <br /> dwg <br /> 'COMMENTS: S b 1 L t"k1�S u (� l bvJ !� -� t(L D(� <br /> NOTE: OFFSITE BORINGS REQUIRE ACESS 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 prepa d this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> Regul ' ns,a d a <br /> Rules aid ll plicable California State Laws. T r /� <br /> Signed x <br /> , �/ Title/Company S'rA� r� 1,0��5// 1 v, NL�a 4-E-JAw,,0,0u1 7-,a_ <br /> Print Name 44 - -DD7S"'j Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By �� Date Issued ! ( l Area <br /> Grout Inspection By L; Date inal Inspection By <br /> Date <br /> Destruction Inspection <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODESFEE INFO AMOUNT REMITTED CHECK# REC'D BY� DATE PERMIT I SERVICE REQUESST,# INVOICE <br /> Z 9. ! j� SR# <br /> C-57_ WC -WAIVER_ C-57 Letter of Auth rizat nit 51 per it_Encroachment doc_ 1/25/02 <br />