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bb/1Lj 10b'1 14: Z i94Jy <br /> r it i n r Luur[ <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HF-ALTH DEPARTMENT (EHb) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NQN�tEFUNDABLE P M DtPIRES i YEA1t FROM DATE ISSUED <br /> w6rU described. This Application is hereby made to San Joaquin County far a pe it to dards ct aildfor Jaaqun County Envuvn ntal Health1DepaRmnt 02110n is a In compliance with San <br /> Joaquin County Development Tide,Chapter9-1115.3 and the A5506so!~,s�•) 2 f <br /> L(N rose Street Citylq=A (V/ �`Et <br /> WELL Location te} t,' 33- City %A nPROPERTY OwnImp ddress <br /> �L• Y� I ,,,,cess - <br /> CDT CantrscEar 1.11�J <br /> �Q }CIYddras_ 1��T1f7i'1 `7t Cit71�-�tv1LicfP�_P�one7�� t <br /> Consultant 1 Sub Contractor "" <br /> Township Range Section <br /> GIS Coordinates:X Y <br /> WO:TO BE PERFORMED: [I DI=STRUCTION(choose type below) <br /> iQ NEW WELL BORING(CPT,GEOPROSE,HYDROYP1UNCH.HAND-AUGER,OTHER") Q OYER-BORE <br /> OIL BORING 9 PRESSURE GROUT <br /> []WELL# Grout SpeciticationS: <br /> *Othor: <br /> COMMENTS: <br /> DIA:- <br /> ME OF VYEtl. INSTALLATIdN TYPE CONSTRUCTION SPEGIFRCA'110NS <br /> DIA.OF 80REHOLE AC1��,dMULTiPLir CASINGS?0 YES `�1`tD WF�L CASING DIA <br /> U MONITORING ❑HOLLOW STEM nyE OF CASING: [I EL LY PVC a OTHER:_ <br /> �A�ON a AIR HAMMER1i]RNEN CASING THIGKNEss � T�2EMlE TYPE TO DE USED: 0 AUGERS I1 HOSE <br /> p VAPOR p MUD ROTARY DEPTH OF GROUT SEAL <br /> p,a1 SPARGE USH POINT GROUT SEAL PUMPED: d Yes n No (NOTE: M IMUM FREE-FALL DEPTH IS 3(l'} <br /> SOIL BORING pl�ANb AUGER GROUT SPECIFICATIONS: <br /> tOTHER:----------J3 OTHER APPRQX.BOF2lNG DEPTH <br /> BOLTED TRAFFIC BOX or D STOVEPIPE <br /> CONDUCTOR CASING PROPOSED? (lf YES,lis!specifications here)' <br /> *COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS�O ENCROACHMENTRALL � 5 PERMITS.ONS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE <br /> hereby certify that I have prepared this application and able Californiaorkl State Laws.be done in accordance with San.Jaaquin <br /> County Ordin n ule Regulations,and f PP <br /> >>..rFf,C �jYCyo,Q_.TitlelCAmpany �� <br /> Signed x l Date 'Z 7-0 Z_- <br /> Print Name 'C ' "" l . <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FIDE,ADDRESS', <br /> y <br /> WORK PLAN RATED' a` � <br /> Data Issued <br /> Apprcaton Accepted By bate (� OZ Final Inspection By Date <br /> Grout Inspeaion I3y <br /> Date <br /> Destruction Inspection BY <br /> COMMENTS l CONDITIONS: <br /> ACCOUNTING ONLY: AID# cars <br /> PE E <br /> CoDS FEE I14FO AMOUNT REMITTED CHECK f# FtEC'D BY DATE pERMR l Sf=RVICE kEQUEsT 0 INVOICE <br /> r5,;q 4 sR# <br /> ���5loz <br /> C-57 WC -WAIVERC-57 Letter'of Authorization to sign permit—Encroachment doc <br />