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WELL PtRMIT APPLICATION FOR,,, <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 />KNIT 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 />WELL Location J01,16 <br />Assessor's <br />l�! +� (� Cross Street C�c� City -) L�� lw-� Z,p ���-3 Parcel#�_ <br />PROPERTY Owner K Litt C� '(��� Address PO )r' City �'4/ �� Zipj�S�d2 PhorA ' 52 Z 5� <br />C-57 Contractor 4G(.A41ez-1 b AddressK37 cs/�6Le� CityE%�p��Lic#OFDA-I 'hone#"� <br />Consultant / Sub Cntr Address City Lic# Phone# <br />GIS Coordinates: <br />Y <br />WORK TO BE PERFORMED: <br />EW WELL / BOR!NG ( CPT, , HYDROPUNCH <br />0 SOIL BORING # <br />0 WELL # <br />*Other:_-_ <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING 0 HOLLOW STEM <br />0 EXTRACTION 0 AiR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE / Ozone/PUSH POINT <br />kSOIL BORING 0 HAND AUGER <br />0 OTHER:_0 OTHER <br />*COMMENTS <br />Township Range <br />HAND -AUGER, OTHER*) <br />Grout Specifications: <br />Se <br />p DESTRUCTION! (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE --1 "— �/IULTIPLE CASINGS? 0 MULTI-LEVEL? 0 WELL CASING DIAt�4- <br />CASING THICKNESS /yn- TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL 6-, 5 ��TREMIE TYPE TO BE USED: R PUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes .,gNo (NOTE: MA :IMUM FREE -FALL DEPTH IS 30') <br />%SCK— <br />GROUT SPECIFICATIONS: PCV-, l'�- <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications he <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 California StateLaws. n <br />Signed x l� Title/Company—�� C�!t%7 1 5-)— /�7 CIE <br />Print Name 1-/! //, c-. 1,-44&- - Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: Z�U <br />WORK PLAN DATED: <br />Application Accepted B / C. _Date Issued Z3 U 3 Area J -Jr <br />Grout Inspection By Date 2 t �p�3Final Inspection By �irn� a T f G <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: O -F L ` ,-Fro r 6 r ia q S -2 � �65ee- . <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY DATE RMI T / SERVIC <br />INVOICE <br />350 I <br />*'w-1,60 <br />ao <br />,�,' �- <br />l ` ���',z 5.0: ((.)335`'7 8 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit ---Encroachment doc8/29/02 <br />