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APPLICATION , RM SITE <br /> WE,.. PERMIT II <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Sitockton, CA., 95202 <br /> (209) 468-3449 <br /> I <br /> NON-REFUNDABLE PERMIT EXPIRESi YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County <br /> for a <br /> and permit <br /> to worts ct andfSan or agtalll the work County Environmental al isHealthapplication <br /> Dep its made in compliance with San <br /> Joaquin County Development Title, pAssessor's <br /> }� � Z;P Parcel#city <br /> WELL Location � Cross Street i <br /> qsz% <br /> (' Address,�ax� City {t Z:per Phone# <br /> PROPERTY Owner II <br /> C-57 Contractor <br /> Address S3C City�_ZIp3�Lic# Phone# ,, 1 <br /> ,�ZAddress Cityfe _Lir.# Phone# $I� M <br /> Consultant I Sub Contractor — <br /> g�p <br /> Y Township M Range Section ! <br /> GIS Coordinates:X ;I <br /> ERFORMED: a DESTRUCTION(choose type below}. <br /> EW WELL BORING(CPT,GEOP ROBE,HYDROPUNCH,HAND-AUGER,OTHER') n OVER-80RE <br /> a SOIL BORING# ©PRESSURE GROUT <br /> ,VNELL# 0 <br /> Groit Specifications: I� <br /> 'Other- <br /> COMMENTS: I! <br /> I� <br /> TYPE INSTALLATION TYPF CONSTRUCTION SPECIFICATIONS <br /> TYPE OF WELL <br /> ONITORING HOLLOW STEM DIA.OF BOREHOLE j MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:Z + <br /> EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS��ut� _TYPE OF CASING: a STEEL XPVC D OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 1 t _TREMIE TYPE TO BE USED: Q AUGERS �8 HOSE <br /> a AIR SPARGE g PUSH POINT GROUT SEAL PUMPED: D Yes 'No (NOTE: MAXIMUM FREE-FALL DEPTH is 3o'J <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: �� <br /> OTHER APPROX. BORING DEPTH Iq �- BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> ��� I <br /> Q OTHER:_0 I if YES,lists specifications hese): <br /> . CONDUCTOR CASING P i OPOSED. ( P ,i <br /> `COMMENTSL.l(` f ` 1 <br /> : I IE <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS 'IN ADVANCE FOR ALL REQUIRED INSPECTII�NS. <br /> I hereby cern th h ve prepared this application and that tihe work will be done in accordance with San`Joaquin <br /> County Ord' a es les and Regu ns,and all applicabl i California State Laws. <br /> II <br /> Signed x Title Company I <br /> Date <br /> Print Name �l DEPARTMENT USE ONLY i <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Date issued Area <br /> Application Accepted By ' Date <br /> Date Final Inspection By IN <br /> Grout inspection By ; � I I <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: S ii. <br /> ACCOUNTING ONLY: AID# <br /> CHECK# RECD BY DATE PERMIT I SERVICE REQUEST <br /> PE CODES FEEINFO AMOUNT REMITTEDSpff <br /> INVOICE <br /> of " 1/25/0� <br /> �_�� WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc ;i <br />