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APPLICATION FORM <br /> WELL PERMIT SITE <br /> MITIGATION <br /> v / SAN JOAQUIN COUNTY <br /> UNIT IV <br /> ENVI -i4MENT'AL HEALTH DEPARTMENT (EHD) <br /> 24 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ; (209) 468-3449 <br /> Ix <br /> "�'•'�!:ice, -rF' <br /> �,C,,5 NbN REFUNDABLE PERMIT EXPIRES 1 YEAM <br /> R FRODATE lSSU£D <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 8-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location,�Q Cross Street' £City —�PP2reet#���. .&4p <br /> PROPERTY Owner 1 a Address S��*t�' City Zip Phone# -�',�;�"-2oez- <br /> C-57 Contractor U ti a Address& Y ��� City�Pdf� ZipLic# Phone# �Q�f1 <br /> Consultant/Sub Contractor('rPOSC Address , (/ 2.1^r City_ Lic#Phone#s �9dZP3 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> D NEW WELL f BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER OTHER-) ESTRUCTION(choose type below) <br /> D SOIL BORING# OVER-BORE <br /> a WELL# PRESSURE GROUT <br /> *Other: Grout Specifications: GmGss` Z Z`�% ` <br /> COMMENTS' fJ/'PS SU r-C G1 YOr!r 3 /*1 04 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> -ZAONITORING D HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?D YES 11 NO WELL CASING DIA: <br /> D EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: D STEEL 11 PVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: U Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 1)SOIL BORING D HAND AUGER GROUT SPECIFICATIONS: <br /> D OTHER-._0 OTHER APPROX.BORING DEPTH €1 BOLTED TRAFFIC BOX or 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 /> I hereby certify that 1 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 /> Signed x TitieiCompany v n�fd'�fPci `P V <br /> Print Name STPt�G �ct�r r� Date_ <br /> DEPARTMENT USE ONLY. <br /> SITE MAP IN KNIT IV FILE,ADDRESS: Z I= 1� <br /> WORK PLAN DATED: <br /> Application Accepted.By <br /> �n�P��✓� Date Issued t 1' 0 Area <br /> Grout Inspection By ` Date _Final inspection By Date <br /> Destruction Inspection B Date lU 07 AA ,,. , ,., <br /> COMMENTS1 CONDI710N5: 6 9 t i�(l � ,�t t-� mut^•( <br /> ACCOUNTING ONLY: AID# <br /> PE CODES I FNTREMITTED CHECK# REC,'DaI i CATE PERMIT I SERVICE REQUEST# INVOICE <br /> SR# <br /> C-57T WC_-WAIVER C-57 Letter of Authorization to sign pert�it_Encroachment doc_. 1/25/02 <br /> 7 <br /> `' `� //�r /j / q"llr,7 <br />