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WELLtERMIT APPLICATION FloRM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> Q \� ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <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 Assessor'sb <br /> ��-7g( t. COr(SrocK fZD. Cross StreetjACl<�� City ST�CK7Ty�J Zip95��5 Parcel# <br /> WELL Location Phone# <br /> PROPERTY Owner q3 —q <br /> )<R6 <br /> R 15 T14 Address S City Zip <br /> � vALL.p 522 ��386 Phone#Z-7a�357d <br /> f(SC}f a/vv Address39 rq S )4��t'S -FL' City 5?,Z,-t5 Zip9Li <br /> C-57 Contractor cS��'V 5023 <br /> rz0 (-7l t{ �iArrJ ST. city— <br /> GIS <br /> Phone# <br /> �RC)U VD Ze Address ' <br /> Consultant/Sub Contractor �J <br /> Y Township <br /> oc.� Range 7� Section <br /> GIS Coordinates:X <br /> O-RK TO BE PERFORMED: 0 DESTRUCTION(choose type below) <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDF�OPUNCH,HAND-AUGER,OTHER*) 0 OVER-BORE <br /> "SOIL BORING# � 0 PRESSURE GROUT <br /> 0 WELL# Grout Specifications: /VOAT- <br /> Other: :1:Z: <br /> COMMENTS: Trow/r'6S <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> t� <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ <br /> AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 EXTRACTION 0 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL <br /> : 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30 <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED ') <br /> \rllzOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: or 0 STOVEPIPE <br /> APPROX.BORING DEPTH �� 0 BOLTED TRAFFIC BOX <br /> 0 OTHER:�-0 OTHER <br /> CONDUCTOR CASING PROPOSED. (if YES,list specifications here): <br /> "COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENTFOR ALL REQUIRED PERMIT <br /> Sores. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN AD <br /> hereby certify that I have prepared this application and that the work ill be done in Laws. accordance with San Joaquin <br /> I Y Y <br /> County 7%nces, Rules d Re lati nd all applicable Califorri� Title/Company <br /> Signed x '� 3ate 2� 0� <br /> Print Name GI DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Date Issued y/lDl6Z- Area <br /> Application Accepted By L Ins Final ection By Date__ <br /> ,� p <br /> Grout Inspection By "/ P Date <br /> Date <br /> Destruction Inspection By Z w <br /> COMMENTS/CONDITIONS: 3t�r <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> dZ QD4# O6 S l <br /> 1/25/02 <br /> C-57 WC=WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ <br />