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WELL PERMIT APPLICATION FORM <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 />'Z,1 Z Z 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 Joaquin County <br />Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br />n Assessor's <br />NELL Location 44;2-�-/f� r p� v"y Cross StreetG!_CT/__��_City 2h Zjp� - Parcel# <br />3ROPERTYOwner r� A) yt, Addressr1 d�kl <br />S Citys %Zipy�Zgphone# 02&4 <br />3-57 Contractor w� E _qAZ A(4T ress V l, � !7 f� Qf= ity S p `,�c# ' 7Phone# q1 - 62-!?-7'2� `r <br />Contractor /65E <br />24�0 6 <br />Address �3onsultant,'Sub <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />07 <br />DATE <br />31S Coordinates: X <br />Y <br />Township Range Section <br />NORK TO BE PERFORMED: <br />EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />,eSOIL BORING # <br />0 OVER-8CRE <br />0 WELL # <br />0 PRESSURE GROUT <br />Other: <br />Grout Specifications: <br />30MMENTS: <br />YPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />yMONITORING <br />�OLLCW STEM <br />DIA. OF BOREHOLE f MULTIPLE CASINGS? 0 YES aN6 WELL CASING DIA: <br />I EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING. 0 STEEL fflSVC 0 OTHER: <br />I VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL&/) > 2 — TREMIE TYPE TO BE USED: _aAIJGERS a HOSE <br />I AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: 0 Yes -"o (NO,jE: MAXIMUM FREE -FALL DEPTH IS 30')^I <br />I -SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS: POLI ova . <br />I OTHER: <br />n OTHER APPROX BORING DEPTH &0 5aOLTED TRAFFIC BOX or 0 STOVE PIPE <br />� <br />'' nn <br />_ <br />�O CASING PROPOSED? (if Y <br />CO_NDDU%CCTES, list specifications here): <br />tel_ <br />COMMENTS: Iv' <br />l�`nQ;/�/� <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 />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br />tules and Regulations, and all applicable Califomia State Laws. ] <br />>igned x wl� Title/Company CCI ! 6� tcS-('L <br />'Tint Name /%� �7� C/7 %%) � Date Z <br />DEPARTMENT <br />/USE <br />�ONLY / \7 <br />;ITE MAP IN UNIT IV FILE, ADDRESS: �r�2 �Q,LTK O7vct�I/111�1 I ! <br />YORK PLAN DATED: <br />application Accepted By v W- ate Issued( <br />rout Inspection 8y Date Final Inspection By <br />ii <br />)estruction Inspection By ate <br />:OMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />SR# a Z <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ 1/25/02 <br />