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t,) Area <br />Date <br />Y .2 <br />Date A37///0 <br />Date Issued <br />Date Final Inspection By <br />Date <br />Application Accepted By <br />Grout Inspection By "-771.. <br />Destruction Inspection By <br />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 /> <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 />, jo <br />WELL Location gay 3 E Cross Street /*/-7I City <br />Assessor's <br />Zip F620e Parcel# <br />PROPERTY Owner M gP Address N) /14-7 cityV-k-M zip9s-V7Phone#04)7 V64 <br />C-57 Contractor 1/40/D2i4 tt 4 g 't dress 33 4, city i011 71Lic#71° 7 hone#76 7 37 7' 4.3ct) <br />Consultant! Sub Cntr 66 Address133 7 1A-624...ti cit,cit_J-1 Lic# phone#0,2Oy /40 G <br />GIS Coordinates: X <br /> <br /> , Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />[I SOIL BORING # [I OVER-BORE <br />1,1-WELL # 112 tij,t) [] PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS -3,/,--,,. CI <br />)1MONITORING 11,HOLLOW STEM DIA. OF BOREHOLE z-----„: -4' 7141ULTIPLE CASINGS? [] MULTI-LEVEL? [J WELL CASING DIA: --- <br />,-. <br />U EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS /IC4 TYPE OF CASING: [] STEEL [] PVC a OTHER: CP <br />ill'VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Y4 ir4 ie.— TREMIE TYPE TO BE USED: if [] HOSE 9 ) <br />[] AIR SPARGE / Ozone G PUSH POINT GROUT SEAL PUMPED: EVes Xlo (NOTE:j/IAXIMUM F_REE:FALL DEPTH IS 30') <br />0 SOIL BORING [] HAND AUGER GROUT SPECIFICATIONS: 7CV2-711-=-7-7 ,. <br />[J OTHER: a OTHER APPROX. BORING DEPTH i 49`) OLTED TRAFFIC BOX or G STOVE PIPE (C\ <br />CONDVOTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS: A/918 vey 4e_ wei( / So, / <br />NOTE: OFFSITE 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 Wet) Title/Company /7'21T <br />Print Name kri, / I Date k, - <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 6203 E GLI., a4-2 <br />WORK PLAN DATED: - - <br />COMMENTS / CONDITIONS: t/1 &L. 1 P., V i..1„) 15' -'-If) 4- <br />ACCOUNTING ONLY: AID# <br />. <br />FAC# e/P---74/-"2?7L. <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT/ SERVICE REQUEST # INVOICE <br />SR# ----/ <br />C-57 <br /> <br />WC <br /> <br />-WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc <br /> <br />8/29/02 <br />