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WELL PERMIT APPLICATION FORM SITE <br /> RECCHVL�D MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> 4 7005 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> " 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> I�I'sVlii�;'dl`�1E4�1T �r�LT1'. (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 DepartmentAssessor's <br /> / N / /J G-Zi '77� Parcel# ,�./•3 <br /> WELL Location.?/ADO �'�'U'a7ll /(ol Cross SVeet/��SC4� PYO ACity 5--4:: P <br /> PROPERTY Owner,( `p f �4�Address- ��ol/�'r ?G�CitY Zip Phone# <br /> J�X 6A19 P <br /> C-57 Contractor U Address Ci l Zi Lic# Phone# %` J,7y� <br /> Consultant/Sub Contractor ltlS� G-'�y Address vp City Lic#l�15� WW Phone t� , <br /> l..*,6.7 ya <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER') DESTRUCTION (choose type below) <br /> eSOIL BORING#2 0 OVER-BORE <br /> # / _ 0 PRESSURE GROUT <br /> 0 WELL'Other: Grout Specifications Gf Gsf �^ <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE ee MULTIPLE CASINGS?0 YES [I NO WELL CASING DIA:NW <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL /S TREMIE TYPE TO BE USED: n AUGERS 0 HOSE <br /> 0 AIR SPARGE >01PUSH POINT GROUT SEAL PUMPED: 0 Yes /*<No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,.$,'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: G jr-1* G A4 <br /> 0 OTHER:__n OTHER APPROX.BORING DEPTH /S 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> nn / CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: G e0 /� a N ✓j :�-O 4 5 Z� Fr Gsl <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 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 /> Signedx "'�A Title/Company���'�'� <br /> Print Name 7 _e a 'r �dr Date ��05 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: goof <br /> Application Accepted By , <br /> Date Issued /iL/o J Area Cj q 7 <br /> Grout Inspection By �, ' <br /> i Datel C C Final Inspection By Date_ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1/25/02 <br /> C-57,_ WC,=WAIVER_ C-57 Letter of Authorization to Sign permit Encroachment doc_ <br />