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WELL PERMIT APPLICATION FORM <br />f /';;. Hf_'SANOOAQUIN COUNTY <br />rRN'UIR6NNI't!NTAL HEALTH DEPARTMENT (EHD) <br />,04 g.er, Third Floor, Stockton, CA., 95202 <br />03 ,1 - � � 6 (209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <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 />�U(� Assessors <br />Location k ,�, � (Crro�sssSStreet ""� , v ,� City Zi� 3� Parcel# Gr c <br />PR ERTYOwne C� � �r"""Address l�%�fJ CVI/Jr� CT r Zip 05 (Ph�� 7� _�/�� <br />C-57 ContractoP � �'' n'' I� Addres ��� city-------- Zip 5 "(- Lice 2� h -o e g r ��Z� <br />onsultant Sub Cnt� Cx `^ W6 ddred-W'WCL Sl-/ 12PC(ty Lic((#__�r�Phon-el DZ~ �3- <br />GIS Coordinates: X Y , Township 3.5 Range 05 Section 7 � <br />WORK TO BE PERF9B EQ; <br />p <br />NEW WELL / ORING) (CPT, GEOPROBE, HYDr-131 INCH, HAND -AUGER, OTHER-) DESTRUCTION (choose type below) <br />`SOIL BO g-143 . 5 S- I41 f-- [ OVER -BORE. DIAMETER <br />/[] WELL # p PRESSURE GROUT <br />,�p7rOther��y4.>(1%L art\l Cal] _ e ,/j15►x IrJ�� 5 G T SPECIFICATIONS <br />( R eR a n. A _ ' lam__ _ _ .. - _ 1 _ li 1 /1 • 11 JAA . [ /)% f \?.%� <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />[] MONITORING [j HOLLOW STEM DIA. OF BOREHOLE*I[] MULTIPLE CASINGS [] MULTI-LEVEL WELL CASING DIA: <br />[] EXTRACTION [] AIR HAMMER/DRIVEN CASING THICKNESS TYFFa0F CASING: [] STEEL [] PVC [] OTHER: iyA <br />[] VAPOR [] MUD ROTARY DEPTH OF GROUT SEk"Irka It MA d �EMIE TYPE TO BE USED: [] AUGERS [] HOSE <br />[] AIR SPARGE/ OZONE [] PUSH POINT (GP or CPT) GROUT SEAL PUMPED: Yves [] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />`�LSOIL BORING [] HAND AUGER <br />[%]OTHER: OTHER '5/DA LL( <br />j*0t J �l�S 11�7� Id[alvt <br />COMMENTS <br />GROUT SPECIFICATIONS <br />APPROX. BORING DEPTH /.n� '710 f [] BOLTED TRAFFIC BOX or [] STOVE PIPE <br />_iA <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />Vv <br />CP <br />S <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ord' ances, R es and Regulations, and all applicable California State Laws . <br />Signed x Title/Company P/bJ c ct <br />Print Na e 1/ <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: GI/ 12 W <br />C <br />DEPARTMENT USE ONLY <br />� r <br />Application Accepted By l / ^ Date Issued 111116-3 Area_ <br />Grout Inspection By M Date Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# )C)3 <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE MIT / SERVICE <br />INVOICE <br />lol <br />-z- <br />(� <br />sR# <br />C-57_ WC WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/30/02 <br />W <br />