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WELL,ERMIT APPLICATION M SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> 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 /> a � Assessor's <br /> WELL Location;S 7d ! lL �� T 47—cross Street /�/7 /ity Zip rcel#_ <br /> PROPERTY Owner �&/L //6/ —K� Address A4 , J�x 7/�(O City Ziip �7/ one# <br /> C-57 Contractor G� � Z Address ?,57 � %7(/�' <br /> 17 � City� �� <br /> Zip / r,,#(0 7Rone# <br /> Consultant/Sub Cntr Address City Lic# Phone# <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION(choose type below) <br /> SOIL BORING# 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 MULTI-LEVEL?0 WELL CASING DIA: N4- <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 4- TYFE OF CASING: 0 STEEL 0 PVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/Ozone PUSH POINT GROUT SEAL PUMPED: 0 Yes XNo (NO�TEE:"MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: rDrUZ� ✓>iL�I, <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH I 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> _ <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): � <br /> *COMMENTS: �✓� IVl ,L f � EG1 � KI C> �6 re,—O l A7C� <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 Or ces Regulat' ns, and all applicable California tat Laws. <br /> Signed x Title/Company­; 3 <br /> Print Name_ Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Sif 1 ��w�►17� 5'�' �J ��`'TCx <br /> WORK PLAN DATED: 1 & I D 3 <br /> Application Accepted By Date Issued 2 D Area <br /> Grout Inspection BDate 3 O Final Inspection By L��t —� Date 3 d <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35-01 o 2- <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02 <br />