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WELL PERMIT APPLUCATION 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 /> . as obft'2066a <br /> (209) 468-3449 <br /> ILt <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 Joaquin County <br /> Development Title,Chapter <br /> .9-11115..3,and the Standards of San Joaquin County Environmental Health Department. 03 5_issessorIs <br /> WELL Location j I `� LLYI�Efd� Cross Street VA- L. i L City Log Zip �6Z�6 Parcel# <br /> Dgr.+lEl. C'IC'4AJ.T P-C%-4Urlrs'r pp". 5r�jck <br /> PROPERTY Owner LCQjZAIAjf- I"e aF oL Address2291` \;J AAAC 1 L&L AlclCiry�,—c�u� ,x 1 ZiP 20 Phone# <br /> C-57 Contractor �CA(1/i 4C�R tbrc� Addrttess S3-7 , IW� � City_nt-d&t,%;tf Zip�Zel Lic# dZZ7Phone#�'/ -��C <br /> Consultant/Sub Contractor�t�ll�aA(/Lith <br /> 6k6cNyIQI.Address �7 5��� Cty y/cliV Lic# t'LZ�Phone# 7-�a6(, <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE P RMED: �1 DESTRUCTION(choose type below) <br /> NEW WELL ORI (CP T, EOPROB ,HYDROPUNCH,HAND-AUGER,OTHER-) OVER-BORE <br /> 0 WELL ORING# 0 PRESSURE GROUT <br /> # <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2--21—MULTIPLE CASINGS?DYES ONO WELL CASING DIA: i h/ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS t4A TYPE OF CASING: D STEEL D PVC D OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL-7oTAL- TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: �es !00 No (N/OTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> VSOIL BORING D HAND AUGER GROUT SPECIFICATIONS:��PG <br /> ,t0__OTHER: D OTHER APPROX.BORING DEPTH a 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> �+ 2 � CONDUCTOR CASING PROPOSED? /�(if YES,list specifications here): <br /> 'COMMENTS:� cGo(L L {nlCfS 70 u F VC U SCtL / IRAB LJJ47�L� yF S <br /> LF�c L i� 70 S wer ACC 4,9&r ctJ l <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 preparey this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> Rules a I i ns and <br /> 'all <br /> laap licable California State Laws. <br /> Signed x c ) Title/Company s!/�Ff ITI,QVI� Al [z�7/SL <br /> Print Name fLI�L �> Date �2L� y7— <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 3. 2 2 0 <br /> Application Accepted By Date Issued ��/ Area v w <br /> Grout Inspection By �Date_Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# =INVOICE] <br /> 2.901 Sa �i• � 2 ' ti 32g ? sR# 00 2`�3 3 <br /> C-57_ WC/- <br /> WAIVER_ C-57 Letter of Authorization to sign permit./ Encroachment doc -AzM 1/25/02 <br />