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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> f ?Cia3 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> E VfPi)a\lUir- i Ilr-' <br /> PEISMi i/SEtVICESN (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. s 13.1-.77001 <br /> r„�, Cross Street E/V6MITSTCity STp6KTVjj ZipyS203 Parcel# '�" �.S IZOV� <br /> WELL Location *� 1 A� s N 5T -.73 <br /> � <br /> /��We( FIS(toCKTb� Address�2-�j Al. E�'Dcl'-kDa C �D Zip�hone1tZ-01- l3�90 <br /> PROPERTY Owner <br /> $'w- 3-* <br /> 0 , CityADp IWLcO-& 3 hone# S <br /> C-57ContractorGISlaA Address <br /> �EGGFW�� j 571r i3av <br /> `DprVE'CtY•ON sd- D hone# -955 <br /> Consultant/Sub Contractor*9&L9�'GT�L— Address55�` !4[DAITCaoM[ Gtity 'SF Lic# p <br /> a <br /> GIS Coordinates:X <br /> Y,,Township Range Section <br /> GS-g—[ -� g,tf G sB- Z:=1WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> Q NEW WELL/BORING(CPT <br /> , EOPROBE,HYD PUNCH,HAND-AUGER,OTHER`) a OVER-BORE <br /> OIL BORING# 11 PRESSURE GROUT <br /> W ELL# <br /> *Other: - Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS / <br /> a MONITORING p HOLLOW STEM DIA.OF BOREHOLE r MULTIPLE CASINGS?[]YES 1]NO WELL CA�rG DIA: <br /> 11 EXTRACTION 1]AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 1]STEEL 0 PVC a OP R. <br /> Q VAPOR MUD ROTARY DEPTH OF GROUT SEAL`(0rrRXl5F-J1 TREMIE TYPE TO BE USED: I)AUC 1]HOSE <br /> a AIR SPARGE PPUSH POINT GROUT SEAL PUMPED: []Yes a No (NOTE: MAXIMUM FREE-FALL TH IS 30') <br /> ( OIL BORING a HAND AUGER GROUT SPECIFICATIONS: <br /> Q OTHER: []OTHER APPROX.BORING DEPTH (]BOLTED TRAFFIC BOX or �VE PIPE <br /> 03+1 Dl/�) CONDUCTOR CASING PROPOSED? (if YES,list specifications here):�a� <br /> *COMMENTS: 0 N &5 T C> <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMIT�- <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin nc s, les d Regulations, and all applicable California State La/ws., <br /> Signed x Title/Company <br /> Print Name '? V 6 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By o Date Issued 2 O Area <br /> Grout Inspection By Date Final Inspection B 3 1i 12%n Date t O <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: I'S i ✓ 4- Mice &m5m G <br /> ACCOUNTING ONLY: AID# rerrlt <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> O 8�` 00 Ct. D1/ SR# o <br /> C-57 WC -WAIVER C-57 Letter of Autho tz tion sign permit Encroachment doc 1/25/0 <br />