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it <br /> u WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> 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 e County fora d the permit to dards of San and/or <br /> Joaqunl the <br /> wo knty Environmentahisealth DeparfinenapplicatiOn is �de in compliance with San <br /> County Development ment Title, Chap Assessors <br /> Joaquin Co ty P <br /> ross Street / i City ip Parcel# <br /> WELL Location x/%06 //�� <br /> PROPERTY Owner - - / Address t/� K '-s 420City / ./{ �� ZipYhone# <br /> ti . 6L/ <br /> city uji&yziPy a*61350�hone# <br /> C-57 Contractor a ddress <br /> � <br /> � Address 7 /�0",9 1/ '/' Cityi ic# Phone#2 Y <br /> Consultant I Sub Contractor <br /> Y , Township Range Section <br /> GIS Coordinates: X - <br /> WORK TO BE PERFORMED: DESTRUCTIO -(choose type below) <br /> 0 NEW WELL / BORING ( CPT, GEOPROBE , HYDROPUNC HAND-AU ER, OTHER') 0 OVER-BORE <br /> SOIL BORING # 0 PRESSURE GROUT <br /> D W ELL # <br /> Gr ut Spe ifcalions <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORINGh OLLOW STEM DIA. OF BOREHOLE G MULTIPLE CASINGS? 0 YES ONO WELL CASING DIA: i�/ r <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSfj- . _ <br /> TYPE OF CASING: OSTEEL , PVC OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL,'. TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> 0 AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: 0 Yes D No NOTE : MAXIM U FREE-FALL DEPTH IS 301) <br /> SOIL BORING D <br /> HAND AUGER GROUT SPECIFICATIONS: 41 i d -/ /QIa <br /> D <br /> OTHER APPROX. BORING DEPTH /fir I IfBOLTED TRAFFIC BOX or <br /> D OTHER: D STOVE PIPE <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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County and Regulations, and all applicable California State Laws. lZre. <br /> Title/Company, ' <br /> Signed x <br /> Date <br /> Print Name DEPARTMENT USE ONLY <br /> Z � S l �a <br /> SITE MAP IN UNIT IV FILE, ADDRESS : d S LIZA6 <br /> WORK PLAN DATED : <br /> Date Issued Z d Area <br /> Application Accepted Bypate Final Inspection B nrr.✓�- Date �' 3 O <br /> Grout Inspection B <br /> Date <br /> Destruction Inspection By C <br /> Ar 52COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# cera <br /> PE CODES FEE INFO AMOUNT REMfTTED CHECK # REC'D BY DATE PERMIT / SERVICE=# INVOICERft 3 <br /> 1/ 25/0 <br /> 3 I t doc <br /> Authorization to Sin permit. Encroachment- 7 Letter of Aut 9 P <br /> C-57_ <br /> WL -WAIVER_ C 5 <br />