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� n FaNC © WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> 01H 2 f 203 SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> EVVh7I1 MEM HEAD rl 304 E. Weber, Third Floor, Stockton , CA. , 95202 <br /> PERM iT SERVICES - (209) 468 -3449 <br /> NON•REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ <br /> County for a permit to andlor install the work described. This application is made in compliance with San <br /> Application is hereby made to San Joaquin <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessor's / <br /> yAw & p-01i Toe44TDAI Zip 9SLo3 Parcel# <br /> WELL Location Cross StreetC�q�- / <br /> 1 t e S f(��' _Address (/ � �/! 4 _ S f ockk,� Zip J tPhonerr _ - <br /> PROPERTYOwner �, - ) C26g <br /> CSC f ' (A 5 °"' - - <br /> ctrl _ <br /> C•57 ConVacmr_ y Tress_ � U' 'S rr � ?��r � ���� -icr, rnones_ <br /> 1 -DAVE 'OIYoN oR 'D/w scb W�u�.•�rmry 3T•r Sri=- <br /> Consultant / Sub Contractor WFZL-4 I�OCGb Address 555 MUV Eioillwd City SF Lic# aD�J Phon 5 � 'qVY , Township Range Section <br /> GIS Coordinates: X <br /> WORK TO BE PERFORMED: <br /> � r DESTRUCTIONQchoose type b <br /> elow)THOVER-BOREgNEWWELLIBORINGCPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, O <br /> ASOIL BORING # PRESSURE GROUT <br /> 0g% � <br /> ELL # o- I hL 6 � Sr I" 3l /iJ C"q <br /> *Other: ��I d v �--�- S Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING g HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? g YES g NO WELL CASING DIA:_ <br /> U EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: H STEEL g PVC g OTHER: <br /> 0 VAPOR MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: g AUGERS 0 HOSE <br /> g AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: g Yes 0 No (NOTE: MAXIMUM FREE•FALL DEPTH IS 30 ') <br /> 0 SOIL BORING g HAND AUGER GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or g STOVE PIPE <br /> g OTHER: g OTHER APPROX. BORING DEPTH g <br /> 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company <br /> Date <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED : C <br /> � g Area <br /> Application Accepted By f ate Issued l e Date <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By - Date <br /> �., COMMENTS / CONDITIONS:," is �r ��l (eur �T . (I*-��(�l 1, tip <br /> � 1 ,. <br /> I SOL{-I�G � <br /> k' Y ACCOUNTINGONLY: AID# Dern <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # C'D BY DATE PERMIT I SERVICE REQUEST # INVOICE <br /> 310 m <br /> C-57_ WC.-WAIVER. C11157 Letter of Autho Izat n o sign permit_ Encroachment doc_ t�" <br />