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ORIGINAL <br />WELL PERMIT APPLICATION FORM <br />SITE <br />SAN JOAQUIN COUNTY MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />304 E. Weber, Third Floor, Stockton, CA,, 952028Rol. <br />_ i <br />_ <br />(209) 463449 _ <br />NON�iEFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE_ISSUED JUL 1 7 2002 <br />POCation is hereby made to $an Joaquin County for a Permit to construct and/or fnstall the work described. This appllcatle de {[���y� r vyi� San <br />oaquin County Devallopment - i11e, Chapter g-1146.3 and the Standards ocff S&r' Joaquin County Environmental Health Depa�p SUIWVItIV I Itt{�Ll 11 <br />iIELL L tlo .��~� +~ �✓� `Cross Strout //�t���i 9 t Clty �zipJ l p VICES <br />,` -/--- �".-y��,--� <br />ROPERTY Omer ' S Address City p 7 J�oPhone# <br />K57 ConitaCtoY����-i Addree:t`3�i a % c� <br />Sty. 1 �� -y <br />�^� Li-�-:--'-Phone# 3 <br />on9ultant /Sub Contractor �7t� Address �3 S�City � Lia Phorw# <br />ES Coordinates: X, Y , Township Range Section <br />/ARK TO BIE E PERFORMED: <br />NEW WE;LI. /BORING ( CPT. GE;OPROBE, HYDROPUNCH, HAND -AUGER, OTHER") <br />0 SOIL 60RING # <br />YAO O� <br />ONITORING <br />EXTRACTION <br />VAPOR <br />AIR SPARGZ✓ <br />II SISTAI,LNOON TYPE <br />JVOLLOW STEM <br />Q AIR HAMMER/DRfVEN <br />a MUD ROTARY <br />p PUSH POINT <br />SOIL BORING 0 HAND AUGER <br />OTHER__ n OTHER <br />0 DESTRUCTION (choose type below) <br />nOVER-BORE <br />` a PRESSURE GROUT <br />CONSTRUCTION -SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES p 4O WELL CASING DIA: 2 <br />CASING THICKNESS <br />TYPE OF CASING: 0 STEEL j'PVC 0 OTHER:! - <br />DEPTH OF GROUT SCAL1d�_ EMiF TYPE TO BE USED: JU-4,UGERS a HOSE <br />GROUT SEAL PUMPED: ea ,fl -'No (NOTE. M MUM FREE -FALL DEPTH IS 3Q') <br />GROUT SPECIFICATIONS: <br />APPROX. E30RING DEPT OLTED TRAFFIC BOX or 0 5TOVE P1Pt= <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 <br />aunty Or�iances, Rules and Regulations, and all applicable Californ7itate Laws,,, <br />gned x Title/COmpany L /J-( �l r <br />pint Name Date " 7� <br />DEPARTMENT USE ONLY <br />ITE MAP 1N UNIT 1V FILE, ADDRELILL <br />` �6 � <br />IORK PLAN DATED: CI %� A a.m1N <br />apiication Accepted <br />rout Inspection By_ <br />3structlon Ineoectia <br />OMMENTS / <br />ACCOUNTING ONLY: I AID# <br />Date <br />_s <br />Cnfle <br />ssued 7 <br />Inspectlon By_ <br />*EC OVES I FE! INFO l AMOUNT REMITTED I CHECK # R91C'gBY f DATE <br />MrAf.a7 71 <br />�ifj . <br />G57_j[ WC_L-WAIVER— C-57 Letter of Authorization to sign permit <br />"hf <br />!O-ZW -0 2 -- <br />INVOICE INVOICE <br />1/25/02 <br />60 39bd NOiADO1S 39b 8TTTL9V60Z 8T:0T Z00Z/8T/L0 <br />