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WELL PERMIT APPLICATION FOI`F SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 02C"i <br /> "'ai-t'1, - 1 QM 11: 51 304 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 Joaquin County <br /> Development Title,Chapter 9-11115.3 and the Standards of San Joaquin County Environmental Health Department. / Assessor's <br /> WELL Location Q i� l t� Cross Street W( ,`"d1lt City < tir Zip q0 Parcel# <br /> PROPERTY Owner C I?IF Address (4-5-/Q, u3_�CitY x .11, ZipI�r�'h?' Phone# "I V' <br /> Q, ✓tC L' 1 Lic#�'/TI0 Phone# l ��J�- /&7 <br /> C-57 Contractor a, G� f 1� / Ad ress �G 31 ()/h�C (,� City Zip � �����:1�' <br /> /� <br /> Consultant/Sub Contractor Address-W5 5 Vtct� City Li�Phone# 7-I60 -> <br /> GIS Coordinates:X ,Y Township Range Section <br /> W f�C TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# OVER-BORE <br /> tlGELL# li t 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> XIONITORING OLLOW STEM DIA.OF BOREHOLE It MULTIPLE CASINGS?B YES l0 WELL CASING DIA: <br /> EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNES-,- G _TYPE OF CASING: 0 STEEL_)kVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALI�`t TREMIE TYPE TO BE USED:�UGERS 0 HOSE <br /> a AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes Ivo,j NOTE: M IMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: \ �rfit� ` Ce4`,('y1 <br /> 0 OTHER: (]OTHER _ APPROX.BORING DEPTH �Za O BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> ,) CON D CTOR CASING PROPOSED? (if YES,list specifications here): <br /> *COMMENTS: 4n, ,- n <br /> r w / Ver' C7 57-, <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT P MITS. <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 County Ordinances, <br /> Rules and Re lations,a d all applicable California State Laws. <br /> i <br /> Signed x Y� Title/Company <br /> Print Name V t a Date � j 0-:2 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �- <br /> WORK PLAN DATED: / 9 <br /> Application Accepted By CSS- �_ Date Issue Z-' C Z <br /> Grout Inspection By Date Final Inspeion By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit__Encroachment doc_ 1/25/02 <br />