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WELRERMIT APPLICATION FURM <br /> SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> 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 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 3�•'�c,V,t, Ass�ssor s <br /> -WEL -Location 1 S I`I C�� Sc'ot6 -r-ft Cross Street Cid jencL S;. City S c�Rv l Zip .5 DS P"W <br /> J" <br /> PROPERTY Owner Address CityZlp . Phone# <br /> C-67 Contractor IV :yyq Address City Zip Lic# Phone# <br /> Consultant/Sub Cntr �0.����r� c Sc Address 10; <br /> 4S R-,<-14I ngkc M City : Uc# Phone#"%I a -0 4`13 <br /> � � Sv <br /> GIS Coordinates:X 3 7 Sb y ,Township 1r4 fc Section <br /> WORK TO BE PERFORMED: --� <br /> a NEW WELL/BORING(CPT EOPROBE,HYDROPUNCH, AND-AUGE :OTHER•) p DESTRUCTION(choose type below) <br /> V}}�•COIL BORING# S�3-�'i �r 5 OVER-BORE <br /> 13WELL# PRESSURE GROUT <br /> *Other: Grout s: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION P CIFI TON <br /> a MONITORING 13 HOLLOW STEM DIA.OF BORE LE MULTIPL CASINGS?a MULTI-LEVEL?a WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THI ESS PE OF CASING: a STEEL a PVC Q OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF O T SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> a AIR SPARGE/Ozone a PUSH POINT GROUT PUMPED: a Yes o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING HAND AUGER GROU ECIFICATIONS: <br /> a OTHER: Il OTHER APPROX. OR <br /> DEPTH VS a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> // CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> *COMMENTS: Y7 N� ��11� c Z• �'' hi,� %rte `�• c K �i 1C G.;• OU-41 1 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENC OACHMENT 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 /> Signed x i—�" --_ - Title/Company <br /> Print Name L-1T-P_C%S �as �ctv��� �� Date -1`{- c-'z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection ate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDIT NS: <br /> ACCOUNTING 0 Y: AID# Ar„ <br /> PE CODES EE INFO AMOUNT REMITTED CHECK# CV I EC'0 BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# <br /> C-57 W( -WAIVER C-57 Le er of Aut orizotion to sign permit Encroachment doc 8/29/02 <br />