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l ���_ j� WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> F-B '2 u 2007 SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> ENVIRGNM,I^N i fiEAL I F" 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> pERMITISERVICES (209) 468-3449 <br /> NON-REFUNDABLE PERMrr 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 /> nq / / Assessor's <br /> WELL Location /��O �/'GI'ra a�/S e Cross Street 2kic,,/f erecity 4 Zip 9�ParceI#it/3 GYO-/3 <br /> PROPERTY Owner Pjvr617� ycAddress 3// o-I. -City/.144< ZiPc "' Phone# <br /> C-57 Contractor S / Address off/ cityZipLic#-gVTPhone# 6.34 <br /> Consultant/Sub Contractor`�t-a/ �C A,V. Address City��c# V,2:�-_3 Phone#/5� <br /> GIs Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> AEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') D DESTRUCTION(choose type below) <br /> ,{"SOIL BORING# 0 OVER-BORE <br /> 0 WELL# Grout Specifications: <br /> 3 D PRESSURE GROUT <br /> 'Other: fications: C�U S S � �-r��/ <br /> COMMENTS: Z_7_7"-1e4 Q [.✓or ti 11/U 11 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Al <br /> ,]'MONITORING HOLLOW STEM DIA.OF BOREHOLE_MULTIPLE CASINGS?0 YES 00 WELL CASING DIA:,2 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SG4f''__!e// ,TYPE OF CASING: D STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 5- y0 TREMIE TYPE TO BE USED: % AUGERS 0 HOSE <br /> 0 AIR SPARGE APUSH POINT GROUT SEAL PUMPED: 0 Yes �No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,G-SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: i LOSS 6-- —lilt <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? _(if YES,list specifications here): <br /> 'COMMENTS: �j`� s- <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 /> Signed x Title/Company� S�J�Ta - <br /> Print Name r� ++ Date 2 2 <br /> DEPApRTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADPRESS: r7l, 000 1 CtJ1a��iS.LJ <br /> WORK PLAN DATED: /� o <br /> Application Accepted By tC Date Issued Area <br /> Grout Inspection By__26Date 0 / 0" Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> M <br /> AID# certr <br /> AMOUNT REMITTED CHECK# RE C'D BY DATE PERMIT/SERVICEREQUEST# INVOICE <br /> - (� �p Zr d7 SR# 0 7 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ 1/25/02 <br />