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WELL PERMIT APPLICATION FORM SITE <br />MITIGATION <br />SAN JOAQUIN COUNTY UNIT IV <br />NVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />ORIGINA304 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 />�" Assessor's <br />LL <br />WELocation �� I S . LIv1 c of h S Cross Street Ck u vl <br />VC S-' . City yl zip 952017 Parcel# <br />PROPERTYOwner KeVih Basso Address ll+S w,ckav't Wa City S+ock�oyt zip 4520io phone#(Q�Oo�Zo� <br />Fifz�­AW X4 Ranc%10 95`7Z C575s$g7`l <br />C-57 Contractor Wcsi I az q Address SH ,++e- :7 CityGo✓cioVa Zip Lic# Phone# 510 �F9�-WIII <br />l 55y vea c s•1-Co?fi �o -I <br />Consultant J Sub Contractor I C e S Address ""I+- r City 041.0A Llc# Phone#(SIO Lsz 32ZT <br />GIS Coordinates: X <br />'Y <br />Township Range Section <br />ACCOUNTING ONLY: <br />PE CODES FEE INFO <br />WORK TO BE PERFORMED: \/ <br />Q NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) ,DESTRUCTION(c se type below) <br />CHECK # REC-D BY <br />DATE PERMIT I SERVICE-REQU ST # <br />a SOIL BORING # <br />WELL #_ M W - y'T <br />VER -BORE <br />M V4 3 � 06 PRESSURE GROUT <br />'Other: <br />' <br />Grout Specifications: <br />COMMENTS: <br />_ <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />. <br />a MONITORING <br />a HOLLOW STEM <br />DIA. OF BOREHOLE MULTIPLE CASINGS? a YES []NO WELL CASING DIA: <br />—' <br />Q EXTRACTION <br />a AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: a STEEL [I PVC a OTHER: <br />0 VAPOR <br />[I MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: d AUGERS a HOSE <br />_ <br />AIR SPARGE <br />p PUSH POINT <br />GROUT SEAL PUMPED: a Yes it No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />a SOIL BORING <br />a HAND AUGER <br />GROUT SPECIFICATIONS: <br />0 OTHER: n OTHER <br />APPROX. BORING DEPTH BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br />"COMMENTS: <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 It ,j <br />ve preps d tLifsplication and that the work will be done in accordance with San Joaquin <br />County Ordinanc les and Re ulatidns, and all applicable California State Laws. <br />Signed xTitle/Company I e s V I h c til avl I h e_e.✓ <br />1 <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />DEPARTMENT USE ONLY. <br />RwAn=m <br />WORK PLAN DATED:_///��� <br />Application Accepted By -� Date Issued Z Area <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By S �-+� a J Date 3 S�iY 2J <br />Cr1MMFNTS 1 CONnMONS: <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit � EncroaChment cioc, <br />AID# Cep <br />rRev ) �A_ t 62 <br />ACCOUNTING ONLY: <br />PE CODES FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC-D BY <br />DATE PERMIT I SERVICE-REQU ST # <br />INVOICE <br />R# <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit � EncroaChment cioc, <br />