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COPY <br /> 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 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessor's <br /> WELL Locationc2/4000 /2Q.0j?Wfe, Cross Street lQ I'O City aOrV Zip 9'� Parcel#,2/.Y-6W—7 <br /> 01 <br /> PROPERTY Owner�p� Address A?& HG A'/ �G City Zip Phone# <br /> _ Address �. CitZipj7 :Lic# Phone# 3dGG8aY.?y <br /> _-Z <br /> C-57 <br /> Consultant/Sub Contractor 14are- j&e Address 2V7AeV&"4 V/W'S, Lic#Phone#Az F?MY' 9. 7 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPU H,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> p,6OIL BORING# (i 0 OVER-BORE <br /> -WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �ffL <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIAJ�/T <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS—dam--TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS &fiOSE <br /> 0 AIR SPARGE )rUSH POINT GROUT SEAL PUMPED: 0-Yes ,$'�—, (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> fL801L BORING 0 HAND AUGER GROUT SPECIFICATIONS: C��I4f' 9 <br /> 0 OTHER:_O OTHER APPROX.BORING DEPTH_rZQ 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here); <br /> 'COMMENTS: age <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 Regulations, and all applicable California State Laws. <br /> Signed x A Title/Company / ` s-c '-6y-y <br /> Print Name_' a -4 Ard Date y"y <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted Bye Date Issued d�� Area 7 <br /> Grout Inspection By--4 t C'Cr� Date S 12 0(O Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# cert <br /> PE CODES FEE INFO AMOUNT REMfTTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> o2Lgol n1 �)n 1S t& I <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ 1/25/02 <br />