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' WELL PERMIT APPLICATION FORM <br /> � ` S vICEI. MITZQA <br /> ON <br />' SAN JOAt�U1N COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 43 CEC 38 PM 3. 304 E. Weber, Third Floor, Stockton, CA., 95202' -�o�►•, I0� (209) 468-3449 a�/aFrl <br /> C„ � <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM GATE ISSUED <br /> gpplication is hereby nnade to San Joaquin County for a permit to construct and/or stall the work dela abed This application is made In compliance wrth San <br /> Joaquin County Development Title,Chapter 9-1115 3 and the Standards of San Joaquui County Environmental Health Department 0031 <br /> v c..YAA-i>:r Iwi-I Assessors y 0 <br /> NELL —./<)q5 Location W, C14ART.Er W4) mss street �-jAv 1 00fpe City 5T"ron Tp Pa1# <br /> S Ta c�oi� /} <br />�tzOPt~RTY Owner Il; Address f;O, BAX 1 6 City STaV;Tnnr zip 9S�a lPhorre# 2n {,5 X956 <br /> :-57 CorntracLor .4 GR, Address 9 Sin qg%wF R a4-0 _ c,1y A7i P Zzip9y_ Sf3_[.,C# Phone#(9 r5�3�3� m <br />�arnsuttant I Sub catr _ L► Address 7 S: Jv y AP City!l a K/W L c# 7 PhoneA 9 fir}V 47 l0 <br /> GIS Coordinates X _. 'y Township Range Secton <br /> I1K TO BE PERFORM913- <br /> NEW WELLI BORING GEOPROIRE,HYDROPUNCH,HAND-AUGER OTHERI ]3 DESTRUCTION(choose type below) <br /> SOIL BORING# -� , CST_.aZ_ J 3 CPT—�I [I OVER-BORE <br /> 13 WELL# 1 PRESSURE GROUT <br /> lbther Grcut Sp cations <br /> pMM ENTS <br /> 1=OF WELL INS"TALLAIMON TYPE CONSTRUCTION SPECIFICATIONS J,, <br /> MONITORING I]HCLLOW E STEM ❑IA OF BOREHOLE, MULTIPLE CASINGS 1]MULTI -FIE',a WELL CASING CIA <br /> EXTRAGTICN r]AIR HAMMERIDRIVEN CASING THICKNESS N16 TYPE OF CASING g 3lr=EL [I PVC p CTHER-- 1-- <br />(VAPCR (I MUD ROTARY DEPTH OF GROUT SEAL_LMAf -TREMIE TYPE TO BE USED L]AUGERS `XHOSE <br /> ARGE/Ozont?�PUSH POINT GROUT SEAL PUMPEC AYes ]I No (NOTE: MAXIMUM FREE-FALL. DEPTH IS 30') <br /> BORING ,t]HAND AUG2R GROUT SPECIFICAMONS T <br /> a OTHER 11 OTHER APPROX.BORING DEPTH � ]]BCLTEO TRAF9C BOX or 11 STOVE PIPE <br /> '- • CONDUCTOR CASING PR OSED� (if YES fist specnHcatons here) <br /> JMMEidT'S W Q !v J N n <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS 1N ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin <br /> aunty Ordinances, Rules and Regulations, and all applicable Californs tate Laws <br /> Signed x TitlalCcxrnpanyb <br />�rrnt Name i� a V Date_ / <br /> DEPARTMENT USE ONLY <br /> LITE MAP IN UNIT IV FILE,ADDRESS: ! At. d�UA <br /> ORK PLAN DATED: LQ�� <br /> L <br /> ation Acceptad By lite issued Area �� 4 <br /> Inspection By Date Finn Irdpecllon By Date <br /> Destruction Inspection By Date <br /> OMMEN IS I CONDITIONS Y <br /> UNTTNG ONLY AID# <br /> PE CODES FEE INFO AMOUNT REM T TED CHECK# RECD BY 13ATE PERMIT I SERVICE REQUEST# INVOICE <br /> f SB 474. ! -09e.003� SS <br />[-572LWC -WAIVER C-57 Letter of Authorization to sign pertnit Encroachment doc 8129/02 <br /> C <br />