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WELL PERMIT APPLICATION FORM SITE <br /> RECE SED SAN JOAQUIN COUNTY - MITIGATION <br /> l� UNIT IV <br /> cep - 3 2006 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENV1RONi�,ENT HEKIc i (209) 468-3449 <br /> PER;�II, <br /> � -r, .rc�RVIGEJ <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 /> /w,�//NN'' Assessor's t� <br /> WELL Location Cross Street 7111 Lt0f4//S City Zip!7�1:7 Parcel# <br /> PROPERTY Ownerwase 5;rl G Address�05r/'A'dy ..—city. �rG Zip S 4�hone#��677� y/04 <br /> C-57 Contracio ..-Address,& Ci pc/g�, Lic# Phone# <br /> c# /o?�� Phone# <br /> Consultant/Sub Contractor�PO/�1 tP /97!/ Addresst2 <br /> City <br /> GIs Coordinates:X,,y,,Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> 0VEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') Q Q OVER-BORE <br /> Q SOIL BORING# <br /> WELL#3 W�� Q PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING OOLLOW STEM DIA.OF BOREHOLE��MULTIPLE CASINGS?Q YES 00 WELL CASING DIA,? <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS-5-e// 9W TYPE OF CASING: Q STEEL AfPVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 10�1' S TREMIE TYPE TO BE USED: tirAUGERS Q HOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: Q Yes / o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q <br /> SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: C/SSS <br /> Q OTHER: Q OTHER APPROX.BORING DEPTH D MOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CO UCTO/RR CASING PROPOSED? X1 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 I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regula ions, and ail applicable California State Laws. <br /> Tttie/Company�l"ro - �y"PD e- <br /> �'��/. <br /> Signed x / <br /> Print Name S�P�/ L� Date <br /> DEPARTMENT USE ONLY, <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2°<1 <br /> WORK PLAN DATED: l D o4. Q <br /> U Date Issued Z � D& Area 9/ 7 <br /> Application Accepted By k ►�.w^T e� <br /> Groutlnspection By <br /> Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: top S <br /> kAC,,,ONLY:COUNTING AID# certr <br /> EE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> - 8� o� 2/�y S SR# <br /> C-57_ WC -WAIVER C-57 Letter of Authorization to sign <br /> /permit Encroachment doc_ 1/25/02 <br /> A 27-6163Stb3 �?5 d-?"I- `f 702, `Ut" `'� c/o 4 <br />