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WELL HERMIT APPLICATION lFiUR UI S 1 s';� <br /> ' SAN JOAQUIN COUNTY MITIGA- IONi <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ' 304 E. Weber, Third Floor, Stockton, CA-, 95202 <br /> (209) 46 8-3"9 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> tp,lium <br /> cation is hereby made to San Joaquin County for a permit to construct and/or install the work described This application is made in compiiance mth San <br /> County Development Title,Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> C I Ty M A l41 1 F-c A .l•Es5PE S}f eel k �V1 Assessors <br /> ELL Location R�t�yF_ L,,A y_Cross Street y�5c m,t£, Aw, City l'r 09ry mzip 9553 tv Parcel# <br /> 2OPERTY Owner <i M�iv rr erg, t".a v� Ad red ss W, C Q n City ,ry lA ZIp Phone#2Gs Z3 1 $4 `r <br /> i'q`'� q qnn N o <br /> C-57 Contractor C SL F. Q r n Address illa�i75 Qmr- . . I M)tcity��Ro��A Zip 95L5�Lic# 7 75]t3Phone#�f 1(� �, k 1t <br /> �nsultantlSub Contractor4AVAn/� D FnU:ro�►rnPn Address 5 7 S v.! R� Ci 5 <br /> � �l}.. ... ty, TaCK?u•NLic#k�4Z2�Phane#Zuj tl�7f`00 <br /> GIS Coordinates X Y Township Range Section <br /> ORK TO BE PERFORMED <br /> (=1111 WELL I BORING(CPT GEOPROSE,HYDROPUNCH,HAND-AUGER OTHER") ©DESTRUCTION(choose type below) <br /> ©SOIL BORING# p OVER-BORE <br /> `WELL# (ill M1`1fa�jTA W'IZ pPRESSURE GROUT <br /> her- Grout Specifications <br /> C <br /> MMENTS 5�- f-} ,D vjc Z n o 2r <br /> ' OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> NITORING _) OLLOW STEM DIA OF BOREHOLE « MULTIPLE CASINGS a YES/� O WELL CASING DIA <br /> nEC CTION U AIR HAMMER/ORIVEN CASING THICKNESS 3k h ��4 TYPE OF CASING 0 STEELN Ii PVC OTHER /jEF/Q� <br /> JWR 9 MUD ROTARY DEPTH OF GROUT SEAL 2-5 P TREMIE TYPE TO BE USED .)�AUGERS q HOSE <br /> ARGE 0 PUSH POINT GROUT SEAL PUMPED p Yes )R�io (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING [J HAND AUGER GROUT SPECIFECATiONS [� _ T rG— <br /> OTHER - __I]OTHER APPROX BORING DEPTH I" BOLTED TFAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSE (if YES,list specifications here) <br /> OMMENTS. <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 /> tuntyereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> Or Lnances, Rules and Regulations, and all applicable Caltfomi a Laws / <br /> Stoned x C c Title/Companel <br /> nt Name Date <br /> DEPARTMENT USE ONLY <br /> tE MAP IN UNIT IV FILE,ADDRESS: <br /> RK PLAN DATED: <br /> out <br /> lication Accepted By ��" " Date Issued 2 Z� Area <br /> Inspection ByV NV Date Final Inspection B4 Date <br /> D struction Inspection By Date <br /> MMENTS/CONDITIONS <br /> NTING ONLY AID# <br /> eery! <br /> E CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3 l�[ <br /> S1 00 l 4-�q ��� sR# 3 <br /> 57 WC -WAIVER C-57 Letter of Autho z to o sign permit Encroachment do1/25/02 <br />