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-4L PERMIT APPLICATION FORM SITE <br />`ir �,l SAN JOAQUIN COUNTY <br />MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />04 MAR _9 pM 1:10 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 <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />T 1^ /�Assessors s� <br />�j-lc <br />WELL Location I ``V l ) : E l Doul Iy Cross Street city � Z!p 20/JParcel# 5 / <br />SoHAL Av-> A �' jc�l�� jc Ul I Dcr'dC, �7 Sz�'� <br />PROPERTY �� ��//���� 2 t <br />OwnerU�G�ir\ Address r> fU CG Lh City��ZipPhone* <br />—�_ <br />C-57 Contractor E Address i AJa7,"0 6) City (;:.1cye, Zip ^VLic#0G01Phone# <br />Consultant/ Sub Cntr G Address q� ���C1ly) Q�City &_Lic# �,0 7- hone# (20`7) 1—�Di>/• <br />GIS Coordinates: X , Y , Township Range <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING <br />0 SOIL BORING # _ <br />)i/VELL #_j <br />,0 Other <br />COMMENTS: <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') <br />Section <br />p DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />r <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS It c� <br />P'MONITORING HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Z Q <br />r <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL f—S Z TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br />0 AIR SPARGE -1 OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS�,bl� 1,,L -,1,,L -,e, -v+. <br />0 OTHER: %t <br />0 OTHER APPROX. BORING DEPTH rp YBOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />448 WCRKING HOURS NOTICE REQUIRED FOR 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 Q 6 Id , 'Tit!e/Company � `� l Lj <br />Print Name &4T-tw� L - b� Date — `—uA <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: _ fI /,l <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />o.4 <br />Date Issued •. ', / rea <br />)ate Final Inspection By 1 V ,-L11 G \ ^ CjDated <br />Date <br />C-57 WC -WAIVER C-57 Letter of Authorizatl to sign permit_ ncroac ment doc_ 9/30/02 <br />I_ <br />f <br />v <br />Q- <br />03 <br />ACCOUNTING ONLY: <br />AID# FAC# <br />n <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT R <br />INVOICE <br />Li 1SR# <br />C-57 WC -WAIVER C-57 Letter of Authorizatl to sign permit_ ncroac ment doc_ 9/30/02 <br />I_ <br />f <br />v <br />Q- <br />03 <br />