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WELLPERMIT APPLICATION F04RM <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 />Joaq in unty Dev lopment iti , Chapter 9-1115.3 and the Standauls of San Joaquin County Enviro'nrnenta Health Department. <br />'�t1,V,t� ZA Assessor's <br />WELL Loca"n ([` Gl SI Cro+; treet CityS ip Parcel# <br />PROPERTY Owner(' I ty, (ZI4 Address 4f /V' RLD WZI C-i4Zipq'j /Phone# X3 -)— <br />C-57 <br />37 — <br />L Th C1 -Sb l-tt�,.i� /�1�'tJla 111. C C/,� _ 1v5�''f%'7 <br />C-57 Contractor d 'S i I,(.._ Address_ ty 1 vl(✓7f�ip�ic# Phone#���-5 <br />Consultant / Sub Cntr I� (-7 L Address L>31 .S h -L ��Cit�ZZk&l Lic# oiLL- Phone# W7 V.6 <br />GIS Coordinates: X <br />1/ <br />WORK TO BE PERFORMED: <br />0 NEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH <br />3VOIL BORING # <br />/D ELL# <br />*Other: <br />COMMENTS <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMERIDRIVEN <br />0 VAPOR <br />0 J.1D ROTARY <br />0 AIR SPARGE / Ozone <br />PUSH POINT <br />-rSOIL BORING <br />00 HAND AUGER <br />0 OTHER:_ —0 <br />OTHER <br />T <br />HAND -AUGER, OTHER*) <br />Grout Specifications: <br />Secti <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLEZ h MULTIPLE CASINGS? 0 MULTI-LEVEL? a WELL CASING DIA: ' <br />CASING THICKNESS N A, TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL iC-� A, TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />GROUT SEAL PUMPED: Kes � /(NOT MAXIMUM FREE -FALL DEPTH IS 301) <br />GROUT SPECIFICATIONS:�`Y'iL�Aai1 L <br />APPROX. BORING DEPTH / 00 F-Oe>4- o BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS: S/_y A)ct r.! 7Q-3 <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 State Laws. <br />Signed x C (�L)" e%w/i_ �y� �L16 Imo/ Title/Company Or-- ov/1� 1A STC_ <br />Print Name Date 12- <br />SITE MAP IN UNIT IV FILE, ADDRESS: 3 Sc� UL <br />WORK PLAN DATED: 7 <br />Application Accepted By C Date Issued P/ <br />Grout Inspection By Date mal Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT/ SERVICE REQUEST -4 <br />INVOICE <br />7Y'2'7 <br />C-57 WC= WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02 <br />