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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E.Weber, Third 3449Fl or, ton, CA., 95202 <br /> ( <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED plication is made in compliance wish San <br /> t to construct the work described. This ap <br /> Application is hereby made to San Joaquin Count 5.3 and the Standards of San/�o install County Environmental onmental Health Department. <br /> Assessofs <br /> Joaquin County Development Title, P iC�ry (_ _j_L_ Zip��A I Assessor's <br /> 1{,7f1�j 007 1 <br /> P } s b� , Crass Streel y ctyy,�-�'" � <br /> WELL Location dr a 4 C�Zip�_Phone#ZG9 yy6 oZ46 <br /> Ir �. 1 Address ���I w Pt( City D5. 'C 671 <br /> PROPERTYOwner w r City _Zip`/-5201 Lic#� t. Phone#.Z <br /> C ,,,,c+��r't'e Address n <br /> C-57 Contractor yJ` Phone#-��Z y�--S-?-j <br /> ;4,�, �t-tTlo ��io�,� Address <br /> �l:'C��SpnM x�� City • do Lic# <br /> Consultant I Sub Contractor/it Range��Section <br /> Township <br /> GIS Coordinates:X�Y—. <br /> WE <br /> K TO BE PERFORMED: 0 DESTRUCTION(choose type below) <br /> OVER-BORE <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER PRESSURE GROUT <br /> 0 SOIL BORIN G# 10 ' i6 <br /> 0 W ELL# Grout Specifications: <br /> 'Other: <br /> COMMENTS: ,s <br /> INSTALLATION TY PE CONSTRUCTION SPECIFICATIONS � WELL CASING DIA <br /> D OF WELL —�—� DIA.OF BOREHOLE MULTIPLE CASINGS?DYES gNU <br /> ONITORING 04OLLOW STEM TYPE OF CASING: 0 STEEL VVC 0 OTHER: <br /> AIR HAMMER/DRIVEN CASING THICKNESS�.T HOSE <br /> 0 EXTRACTION 0 DEPTH OF GROUT SEAL -� TRE .. TYPE TO M USED: ALUGERS D <br /> 0 VAPOR 0 MUD ROTARY <br /> �SH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIM� PREE2-3' t I ALr D�VYsf (PrPTH IS 30,} <br /> 0 AI SPARGE GROUT SPECIFICATIONS: dJ L I z..->sl <br /> OIL BORING p HAND AUGER 2C���} p BOLTED TRAFFIC BOX or g$TOVE pfF'G '�'�` <br /> 0 OTHERS APPROX.BORING DEPTH�� <br /> 0 OTHER: 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 I have prepare .this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, R les and , gulations, and all applicable California State Laws. // /�= <br /> Tille/Company � / y r CJ r <br /> Signedz k <br /> Dale <br /> rcI Ir t cl1„�4 <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: Area <br /> / L� <br /> P� Date Issued <br /> L nyb <br /> Application Accepted By / .Date__--Final Inspection By Date <br /> Grout Inspection By Date <br /> Destruction Inspection By <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: <br /> AID# r:a rat <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REG'D BY DATE PERMIT I SERVICE REQUEST# INVOIC <br /> j/ll 6'i SR# M3 (2 <br /> �f <br /> Fri i 7 nt doc_ <br /> C-57_ WC—WAIVER_ C-57 Letter of Authorization to sign permit_Encroachme <br />