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WEL&PERMIT APPLICATION FORm-' SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT(EHD) UNIT IV <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 Joaquin County <br /> Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location 433 We S['HSP_ Cross Street-/ city��/�(FD17 Zip Parcel# Assessor's <br /> /y / C- r e <y7yi p, <br /> PROPERTY Owner[/!�6ai//9r/Y L/l�/�lollCttQ� Addres4c 5 �43�CCL,..!City` ed O ZSp 3Phone# .2,/56 <br /> C-57 Contractor lar_ Address-93744 iCc� City,,�f e". Zip��Lic#� 22 hone#y6/ Z�j)�(� <br /> Consultant/Sub Contractor /ffors Address 3Z�� ec City,�iD/'�Cb"Li b Z Phone# 4Fk7- 049 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> jjrNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION(choose type below) <br /> SOIL BORING# 3/J6lP " S Q OVER-BORE <br /> Q WELL# a PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING Q HOLLOW STEM DIA-OF BOREHOLE_MULTIPLE CASINGS?Q YES/YNO WELL CASING DIA: <br /> Q EXTRACTION I7 AIR HAMMER/DRIVEN CASING THICKNESS, _TYPE OF CASING: a ST/EEL a PVC a OTHER: <br /> L <br /> Q VAPOR p MUD ROTARY DEPTH OF GROUT SEATREMIE TYPE TO BE USED: 0 AUGERS HOSE <br /> Q AIR SPARGE WPUSH POINT GROUT SEAL PUMPED: a Yes,YNo/(NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> Q SOIL BORING o HAND AUGER GROUT SPECIFICATIONS: <br /> —� <br /> a OTHER: fl OTHER APPROX. 3C BORING DEPTH Q BOLTED TRAFFIC BOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: <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 County Ordinances, <br /> Rules nd Regulations,and all applicable California State Laws. <br /> Signed xx ' _ ' Title/Company /Qljj 5 <br /> print Name_ fill if &d t Date <br /> 22 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,oA DRE S: �J 3 W Sc-atf 3 �� cP y� <br /> WORK PLAN DATED: <br /> appliption Accepted By Date Issued 3 6 Z Area 7 2 <br /> Grout Inspection By l Date , -5 dfy Final Inspection By �" �0 U Date/d Q <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 3.501 my) 4 �5 1 SR# 3rol�3 <br /> C-57 WC--WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc_ 1/25/02 <br />