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WELL PERMIT APPLICATION FORM Cob <br /> SAN JOAQUIN COUNTY MITIGATIO <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202nno �F <br /> i (209) 468-3449 INECE <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED h � n,�� <br /> SAMe is hereby made to San Joaquin County for a permit to construct and/or install the work descnbed This application e th Ice with San <br /> oaquin County Development Title,Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> NV1RA9NeAsgrqj�9 I!EAL _Z <br /> VYELLLocation 1717 0.-,64 a t, Cross Street T�,�� _St City 5426kto+t <br /> PROPERTY Owner rt Cr cesv^ Address T rlar.v,.. S,d� City S"Eocic�o.+ Zip Phone# <br /> C-57 Contractor -o Address 4~005 Nrottl� Us15D— City Stc[lc�on Zip95zo Ltc#`gv7ZZ Phone#?o`f 467-/bc <br /> Consultant/Su ,{_ <br /> Contractor 1`r�r ,Ce Address Zto We 5...�d 6...1< City Co .Coro 4 Lic# Phone# 61 5- 7`bl' {� 7 <br /> Ihwer+i iL3G <br /> GIS Coordinates X 37 0 576/t4 Y 17,1 o �I 17 L ,Township Range 6 E Section. 10 <br /> WORK TO BE PERFORMED <br /> ANEW WELL 1 BORING(CPT, EOPROB HYDROPUNCH,HAND AUGER,OTHER•) Q DESTRUCTION(choose type below) <br /> Q 50l RING# ��-3. 4:S OVER-BORE <br /> I7' WELL# (I PRESSURE GROUT•Other Grout Specifications <br /> COMMENTS <br /> 'TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING 11 HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?[]YES p NO WELL.CASING DIA <br /> r EXTRACTION d AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING li STEEL [I PVC a OTHER <br /> APOR []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED [JAUGERS I]HOSE <br />,P <br /> AIR SPARGE; )�PUSH POINT GROUT SEAL PUMPED p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 13 HAND AUGER GROUT SPECIFICATIONS <br /> []OTHER OTHER APPROX BORING DEPTH l]BOLTED TRAFFIC BOX oro STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? {If YES,list specifications here) <br /> `COMMENTS 'DbG Aarabs jas- 1CL-d -),2n!;g-11C'0" s;-- /•K <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 l have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, <br /> �Rules and Regulations,and all applicable California State Laws. <br /> Signed x ,i' �H� '-?x�.,/ T-Me/Company fs,1 ✓lCe S <br /> 1 <br /> Print Name /"jA�/� /��+a�� Date 3/4-�za t3L <br /> DEPARTMENT USE ONLLY� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: -O 2 /Q <br /> Application Accepted By <br /> Date Issued �~ ..-� Z Area 4K" <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> OMMENTS 1 CONDITIONS <br /> ' ACCOUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> Z 3 3.5. 2� Zya9r3 <br /> �, C-57 WC -WAIVER C-57 Letter of Authorization to sign permit E croachment doc 1/25/0 <br />