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WELL P�mMIT APPLICATION FOR#' SITE <br />n®leSID SAN JOAQUIN COUNTY MITIGATION <br />UNIT IV <br />�V %40A ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />2m <br />�N 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />MENS NEP S (209) 468-3449 <br />C���QQ�MM (S���\GE NON-REFUNDABLE PERMIT. EXPIRES 1 YEAR FROM DATE ISSUED <br />Application i�Firir�by 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 />� N _ <br />WELL Location / ! ✓i ��f11 �`(� Cross Street V&4r�1 Citys t ZipAssessor's <br />Parcel# <br />PROPERTY Owner /VI 1 r\-;_� p4t-7- <br />r <br />C-57 Contracto <br />Consultant / Sub Cntr i4 66 -- <br />Address 6 ,� 7 S <br />LJ <br />ity aCC. ic<_ Zik�� i` Phone' ' 7-2%h, <br />City ���iC7 %�!O Phone# 3s� !7(�7 <br />City5 �) Lic# Phdger`76 7/ LOb <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE <br />0 WELL # p PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE <br />, a<CNITORING ,-HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE / Ozone p PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 0 1 'f LTIPLE CASINGS? 0 MULTI-LEVEL? 0 WELL CASING DIA:. <br />CASING THICKNESS TYPE OF CASING: 0 STEEL a- VC 0 OTHER: �7 <br />DEPTH OF GROUT SEAL Z 0 PeC7 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE � <br />GROUT SEAL PUMPED: 0 Yes )14o (NOTF: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATION <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 7SOLTED TRAFFIC BOX or 0 STOVE PIPE <br />>I'' L CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS: ��d � rl S lam` l�R 1 /212 <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 CaliforniaStateLaw . <br />Signed x t'da4_ _1 Title/Company <br />Print Name 41!/ P , o P" L - Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: ;Z44 Wes f Hard i n Wa v 5+ock4-on . Cts <br />WORK PLAN DATED: <br />\, U(a ('610rI10r a 20D'3 <br />Application Accepted B V ; e; I Date Issued 311 0-3 Area / 4SR _ <br />Grout InspectionB� �,;� ii `% �1.3iizG» Date Final Inspection By e.4t Date q- el- 0 3 <br />Destruction Inspection By lo,Date <br />COMMENTS/ CONDITIONS: : , U,a*CK MttQrg' A 6i M W W - t <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PE T # INVOICE <br />iso/ <br />or99,od <br />89-00 <br />1 -Si3 <br />SR oo j3 ;z9 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroac ment doc 8/29/02 <br />