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WELL PERMIT APPLICATION FORM SITE <br /> R`� �,�� MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> 2007 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> V1RCNtti I1E tH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> PER�,�111S�RVICES <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 /> nn Assessor's <br /> WELL Location 3<011 !✓ P4ggZ4/*01''O Cross Street%60,-41wificpCity Zipy Parcel# PZ OHO/Z <br /> PROPERTY Owner S?S,�f y�+! ��O S Address P� �'9 X8'1/ cit�J� ..7A 4,1<i Zip?v21.3-PPahone#7/y V' %0'1z'z' <br /> C-57 Contractor S�// Address2,20 Z/ �ps7 :k: City4A2& �QnZip�Lic#Phone# GCS.2 <br /> Consultant/Sub ContractorGPO/kQ'Je, j-a d� Addresses2% 41+le�+►oy/�iiCity � i Lic#_V�3 Phone# �e� <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> WOEW W ELL/BORING( T.GEOPROBE,HYDROPUZICH,HAND-AUGER,OTHER-) p DESTRUCTION(choose type below) <br /> )f SOIL BORING# 0 OVER-BORE <br /> JELL# Grout Specifications: 0 PRESSURE GROUT <br /> *Other: <br /> fications: G/GSs iLf PcT <br /> COMMENTS: Pe arra t 4.0t.).P,4 /,ei <br /> a 'o/i�'f o7 <br /> TYPE OF WELL INSTALLATION PE CONSTRUCTION SPECIFICATIONS <br /> ONITORING .,HOLLOW EM DIA.OF BORN <br /> t MULTI E CASINGS?0 YES)'NO WELL CASING DIA: �� <br /> 0 RACTIO dYaIR HA ER/DRIVEN CASING THIO PE OF CASING: STEEL ,✓g(PVC 0 OTHER: <br /> 0 VA OR 0 M OTARY DEPTH OF GTREMIE TYPE TO BE USED: >q AUGERS 0 HOSE <br /> 0 AIR S GE SH INT GROUT SEAes o (NOTEAXIMUM FREE-FALL DEPTH IS 30') <br /> �SSOIL 0 NG HAND AU R GROUT SPE0 0 ER: 0 OTHER APPROX.BO0BOLTED TRAFFIC BOX orXSTOVEPIPE <br /> CONDUCTOOPOSED? (if YES,list specifications here): <br /> •COMMENTS: / t ��� �6/�rro <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 /> 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 Regulatio s, and all applicable California State Laws. <br /> Signed x / Title/Company CO 4 Sv/7 <br /> Print Name (� �. 47 jr Date 9f� <br /> DEPARTTMEN/T' USE/ lONLY.. <br /> SITE MAP IN UNIT IV FILE, D RESS: �I DOD f C�La IS-e' 94 ^-d`'"'1 <br /> — <br /> WORK PLAN DATED: v n r/ <br /> f� <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By ee <br /> Date/r C Final Inspection y Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: 66_ , r <br /> ACCOUNTING ONLY: AID# certe <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK## RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> j_g0I 9A �!( � O I (.I SR# Ob �7 <br /> 0-1 1C-57_ WC=WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ 1/25/02 <br />