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-3a1 # <br /> LL PERM <br /> IT APPLICATION FORM �;TME <br /> MITIGATION <br /> ' SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPAP11H H 2: 39 <br /> 304 E. Weber, Third Floor, Stockton, CA., 3 2 <br /> ' (209) 468-3449 SAN jotQuj�400U- NTY <br /> Qujf 4 0U- TY <br /> Q <br /> -yy A TT tt�� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR p#gA IDA*y1 Wu�g TMEPdT <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, <br /> ��Chapter 9-1115.3 and the Standards of <br /> San Joaquin <br /> ,,(County Environmental Health Department.Assessor's <br /> G�/O s Ii1/I(SOW7 Cross Street / '�4�k'��r' City r�Gtk� Zip Parcel# <br /> WELL Location <br /> &6 rf,/ �C (o <br /> vv✓ /o'� Address 3 33 AC!>Cc X6.1e City s <` N Zip g�Phone# L/7 7-9277 <br /> 1 PROPERTY Owner 77 co <br /> Citvt I It Zipjs Lic# Phone#S 35 0f-l <br /> C-57 Contractor /-/p 6-e- Address / A-Y Dc <br /> - <br /> tConsultant/ <br /> �Consultant/Sub Contractor <br /> �( �,et v� I'W,er, Address a� S y l l City k iV-'Lic# � Phone# <br /> GIS Coordinates:X <br /> Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> T DESTRUCTION(choose type below) <br /> NEW WELL/BORING(CPTEOPROPING <br /> DROPNCH,HAND-AUGER,OT -) 0 OVER-BORE <br /> # <br /> PRESSURE GROUT <br /> ' 0 WELL# <br /> Grout Specifications: <br /> `Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _ <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE d" MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS= TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 3D TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> ' 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes XNo (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> iSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> /Vt'G �IL cK t q/� <br /> ' 0 OTHER: <br /> OTHER f APPROX.BORING DEPTH 30 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> "COMMENTS: <br /> ' NOTE: OFFSITE BORINGS REQUIRE HOURSCESSIN ADVANCE ENCROACHMENT <br /> FOROACALL R QUIRED INSPEC ONS. <br /> CALL THE UNIT IV INSPECTOR 48 WOR <br /> jI hereby certify I have rep ed this application and that the work will be done in accordance with San Joaquin <br /> County Ordin s, an Regulations, and all applicable California State Laws. <br /> Title/Company .(1 0 ( F""(-0� <br /> ' Signed x <br /> Print Name � � Date � 0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: �1/ �y <br /> ' WORK PLAN DATED: Date Final Inspection By �/ <br /> Date Issued �P Z8-05 Area OG <br /> Application Accepted By Date <br /> Grout Inspection By <br /> -� <br /> ' Date <br /> Destruction Inspection By <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# �er�e <br /> NT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> PE CODES FEE INFO AMOU <br /> 2R0�- � Q1 � l2 D �'� (v-Z3 SR# 00 T� 1/25/( <br /> ' C-57 WC ✓-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br />