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WELL+PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <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 of San Joaquin County Environmental Health Department. <br /> Assessor's c) <br /> WELL Location /50A). SINL�ArFf2_. 4,/e-. Cross Street IJMA"*Ij City 31DL� zip-15'14^4Parcei# 1 S t 0!03V <br /> NtW H <br /> PROPERTY Owner SP)( (e./lo✓ Address o0 .tJ.1JA sr City ft l-5IM Zip9SGtf Phone# <br /> DTD 9r, t. S• ZZ / A. 860r S9i"o <br /> C-57 Contractor / Address City_ R... <br /> ____ __. Zipy"31 Lic# hone# <br /> ConsnIt/iSub CC~�frK'W"OHJ"A 0-ar,,r 5' Address �t �D �7Z0 <br /> 3 �+e✓.T.+n� city SAcFo, uc# Phone# `►« 8G•4•Z730 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,BZIEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# D OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE &// MULTIPLE CASINGS?D YES Aj: O WELL CASING DIA:3 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SDR(t-3/STYPE OF CASING: n STEEL D PVC )jCTHER:14pp9- <br /> D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TYPE TO BE USED: flAUGERS `—dOSE <br /> 0 AIR SPARGE n PUSH POINT GROUT SEAL PUMPED:50511es 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> g SOIL BORING D HAND AUGER GROUT SPECIFICATIONS: 911/b AoA1A,A71Y�Oeg S% Ii8.J1/oa.w'T- <br /> SfLOTHER: THEIR_ A%"V APPROX.BORING DEPTH Zor BOLTED TRAFFIC BOX or IKSTOVE PIPE <br /> CONDUCTOR CASING PROPOSED?_j() (if YES,list specifications here): <br /> 'COMMENTS: <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 Ordinancep, Rules and Regulations, and all applicable California State Laws. <br /> Signed x_—A7>tiyi�✓� '+ —Title/Company <br /> Print Name Wit./ /-t I KAC I An Date IDZ/ZC0�d O <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: L).( C , 7./7 <br /> Application Accepted By, a L� Date Issued Area <br /> Grout Inspection By Date tLOOd Final Inspection By Dat <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> Fnrx <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> (f1 - //s-/ <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc 1/25/02 <br />