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WER PERMIT APPLICATION11uRM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(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 />Assessor's <br />WELL Location SCS; �f ^, yt �'c ' c' Cross Street i City Uv Zip C 7 7% ? Parcel# <br />PROPERTY Own/I�� Addres �" n City ZipPhon <br />C-57 Contractor Ajua.jl:P,-0 %t� � u Address � ���p�+CG< i 4r ,A- City ' t,1 Zip -/S Lic#��Phone#, � 46 <br />Consultant / Sub Cntr / (1l..c'c"MO Address( ��s�i���; �C]� Citys�Ce4_kll Lic# �y Phone# <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL k;, OWN (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />'SOIL BORING # 5 0 OVER -BORE <br />0 WELL # 0 PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE / Ozone <br />PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER: <br />0 OTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS Qk, <br />DIA. OF BOREHOLE " MULTIPLE CASINGS? 0 MULTI-LEVEL? n WELL CASING DIA: 1"//;;Z <br />CASING THICKNESS Al TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL��'1 }7 (If, TREMIE TYPE TO BE USED: 0 AUGERS ,HOSE �\ <br />GROUT SEAL PUMPED: 0 Yes 0 No (NO�E: MAXIMUM FREE -FALL DEPTH IS 301) <br />GROUT SPECIFICATIONS: j00 rl6L,_e_�i C-ec—e If <br />APPROX. BORING DEPTH �Z i) 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />t� <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. ro <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. 9 <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />CountOrdinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x y.--i� Title/Company / (^ lyC; i F " <br />Print Name l 10 14 Ie- VA 11,4,1 11 C(C, <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS' � I � J • Lyw cam- 11 <br />WORK PLAN DATED: I.).1 10 1 <br />Application Accepted By _ -Date <br />Date Issued Ar[a <br />Grout Inspection By `- V�%L- * _Date Final Inspection By z _ ;^ Date J <br />Destruction Inspection By Date <br />COMMENTS / CONDITION <br />ACCOUNTING ONLY: AID# <br />C//SERVICE 'CREQUEST <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT # <br />INVOICE <br />350 <br />lot <br />s `$ <br />3z -?C) <br />C-57 WC= WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ 8/29/02 <br />