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WELLS. ERMIT APPLICATION FM SITE <br /> SAN JOAQUIN COUNTY MITIGA70N <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 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 off San Joaquin County Environmental Health Department. <br /> WELL Location 1126 �" ��>� ST Cross Street Cir✓L{ � City i'� Zip `Parcel#or's <br /> PROPERTY OwnerL /,�TS 50JS Address ✓ ST" City Zip &hone# <br /> C-57 Contractor_Xll~[aC?LO U-' &.Address 837 tis/ City s Zip_ XlrLie# Phone# <br /> Consultant/Sub Cntr Address City _ Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> q NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION(choose type below) <br /> SOIL BORING# ' aOVER--BORE <br /> WELL# 0 PRESSURE GROUT <br /> `Other: Grout Specifications: <br /> C17MMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 MULTI-LEVEL?0 WELL CASING DIA:00,4 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: _ <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ; s>t f TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/Ozone #PUSH POINT GROUT SEAL PUMPED: 0 Yes KIo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> VOiL BORING 0 HAND AUGER GROUT SPECIFICATIONS: !Po117L.+1IrrA ek;vtA.f- <br /> 0 OTHER: p OTHER APPROX.BORING DEPTH_7 /F;Z0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?A* _ (if YES,list specifications here): <br /> *COMMENTS:_ -!Z/L- Ae,<11664 e Y — <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 Ordi�ces, a Regulati , and all applicable California State Laws. <br /> Signed x �'- TiUeJCompany_, __ <br /> Print Name Date 11-WI-0 3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: 3 2003 <br /> Application Accepted By Date Issued ENVIR010�" l l iEALTH <br /> Grout Inspection By Date Final Inspection By ISE VIULS <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTER CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02 <br />