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14� <br /> WEL PERMIT APPLICATION 3RM <br /> SITE=;" . ' <br /> SAN JOAQUIN COUNTY 1 <br /> 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 /> Appfication is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application 15 made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of fSaan Joaquin County Environmental Health/,Dpepartment. <br /> WELL Location ( J Cross Street r `�, ,� ity 1 Zip"/ Parcel#Assessor s037—3 d-49 <br /> 77�7 Ci �I I <br /> PROPERTY Owner •' Address e/ _ � �J ty c Zip�/�hone#_ <br /> C-57 Contractor �t f &dldress 63 -- rt�J F-fX _ City (/ ip /sZc c#�� �Qhone# J j, <br /> Consultant/Sub Contractor �CTri Address • City Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: ' <br /> 0 NEW WELL/BORING(CPT.GEOPR.08 „-IYDROUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> j{ OIL,BORING# Q J� _ "" " a 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 HOLLOW STEM DIA.OF BOREHOLE 2t,GA MULTIPLE CASINGS?a YES ff'NO y' WELL CASING DiAd/4- <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS N��TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> Q VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE )WUSH POINT GROUT SEAL PUMPED: 0 Yes ZNo (NOT)E: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Po,/L;f—L . <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH 17 Fee--T' 0 BOLTED TRAFFIC BOX or' l]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,'list specifications here): <br /> *COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACH MENTOERMITS. <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 /> I/r_ /f <br /> Signed x � J TitielCampany / <br /> Print Name `11c-cam fel Date <br /> -DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: O <br /> WORK PLAN DATED: ..Z'� . ffl <br /> ,M ttP��%� yo 2aoo <br /> Application Accepted By Date Issued_ Area�P <br /> Grout Inspection By Date 2S10 Final Inspection By Date } <br /> Destruction Inspection By Date y, , <br /> COMMENTS 1 CONDITIONS: 56 St <br /> ACCOUNTING ONLY: AID# <br /> �e rte <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE f <br /> 17 s" IW- 114>11IF07- SRU 2223LZ31 <br /> C-57 WC -WAIVER? C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br /> y ii <br />