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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> 1` ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <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. <br /> Assessor' <br /> WELL Location S. '/r Cross Street City Tpr� Zip ZOb Parcel# 7��07-dID-D3. <br /> PROPERTY Owner �� I�bVl Addres.M33 11'T kbCW_. City ! Zip 7v Phone# <br /> C-57 Contractor Address &. WA-FT City�AC•.---Zip �Lic#(27 Phone/�6 � 3 <br /> Consultant 1 Sub Cntr Address A3_:7 r4W CitysftLiC#,4V,?27 Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO.0 PERFORMED: <br /> & <br /> NE WELL BORING(CPT,GEOPROSE, HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION(choose type <br /> e ow) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# UW—1 � 1,y� 0 PRESSURE GROUT <br /> *Other: Grout Specifications: . <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �r p <br /> AMONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 MULTI-LEVEL?0 WELL CASING DIA: 2 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSSC .�Q TYPE OF CASING: 0 STEEL 'PVC a OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL^'40 TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE 1 Ozone 0 PUSH POINT GROUT SEAL PUMPED: XYes 0 No (NOTE: MAXIMjJM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: ?0_TLA+0 -rya r <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH r (BOLTED TRAFFIC,BOX or 0 STOVE PIPE <br /> re //If �� ��, CONDUCTOR CASING PROPOSED?�(if YES,list specifications here): <br /> *COMMENTS:^ <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 I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O • anpcftles and Reg lations, and all applicable California State Laws. <br /> Signed x Title/Company<wrE!(i aLO(xl S/ r!Print Name - Si S Date �2` I r� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By .0-Qi( Date Issued 3 _ Area Lt <br /> Grout Inspection ByDate Final inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: GL e <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES I FEE INFO AMOUNT REMITTED 'CHECK# REC'D BY DATE PERMIT I SERVICEREQUEST# INVOICE <br /> s olry <br /> C-57� WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02. <br />