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FILE COPY <br /> WELL PERMIT APPLICATION 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 /> (209) 468-3449 <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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> /� <br /> Q IFic. Ave , Assessor's <br /> WELL Location '1f'/ Q5 & 'F�c- AVF vi. Cross SLreetYgf,9 '; T. City STOCK ,-, Zip952P-] Parcel# I ) O � -ZYo - l4 <br /> W <br /> PROPERTY Owner p�E f r N C ASS_ 7f a Address 4 y oS PAc Irve R City S TcCY, io.�1 Zip Phone#C20c1� 778 <br /> wts'rfr ,J wesi ?s111 uc#-C l Ik <br /> C-57 Contractor 5-r A4/1 I[ /+��folo+r o.� Address P. u . S„x fb64 ciltly 5a tZip ( Phone#( f , 373-11 <br /> Consultant / Sub Contractor R • Cf , F • Address £937 Sit PI RI) • CitysTcCFo Lic#6$ LZT7PhoneI 01) Y; 711- / DOIla <br /> GIS Coordinates: X.. Y_., Township 0( RangeSection .l <br /> WORK TO BE PERFORMED: <br /> EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br /> p SOIL BORING # p OVER-BORE <br /> l <br /> ;KNELL # w�1 3 p ^r t� p PRESSURE GROUT <br /> 'Other: r Grout Specifications: I C {- %�y}.,r0 / YP E. L� <br /> COMMENTS: .$ F F Mff—f1r -b \A/ 6fK Io .J pATFD IS F� BRweq ton 2_ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 'I 11 <br /> p MONITORING )HOLLOW STEM DIA. OF BOREHOLE /O MULTIPLE CASINGS? 0 YES `$'NO WELL CASING DIA: r <br /> ° 1 <br /> p EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS�_b�� TYPE OF CASING: 0 STEEY APVC BOTHER: I <br /> `VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL SFr 8SG TREMIE TYPE TO BE USED: TYAUGERS 0 HOSE <br /> p AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yess 'Tlo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0SOIL BORING 0HAND AUGER GROUT SPECIFICATIONS: PorilrAo1 Ip r, 1+- <br /> 0 OTHER: N OTHER APPROX. BORING DEPTH So FT $5 (T X,BOLTED TRAFFIC BOX or 0 STOVE PIPE ,( <br /> CONDUCTOR CASING PROPOSED? No ( 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 County Ordinances, <br /> Rules and Regulations, /and all applicable California State Laws- D <br /> Signed itle/Company /A r G . rtTIII � j DatePrint Nam ✓ C . <br /> I, <br /> DEPA TMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : �� "✓�""'� <br /> WORK PLAN DATED : Z �� <br /> Application Accepted By Date Issued •---' QZ Area OrPB / <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 /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment dac 1/25/02 <br />