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WELL PERMIT APPLICATION FORM' : SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT(EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA, 95202 <br /> (209) 468-3449 - <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE=D <br /> Application is hereby made to San Joaquin County for a permit to construct andlor 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 J Environmental Health Department. <br /> WELL Location X353 Ttn�e Qcross Street LE1 { city�l� ap�537� '�a � - " `� �r5 <br /> PROPERTY Owner 17f_ Address j%D 'toy c R c�- --City f��?NVI <br /> rip Phone#_ <br /> C-57 Contractor /� >rfI f Address-3.��11 On7& I __C. ��lrpy� tic9 17SJOPhon g�G q <br /> Consultant I Sub Contractor f t�z- Address City 7Q''[ac# 7 Phone# Y�7`�O <br /> GIS Coordinates:X Y Township Range Section <br /> V13RK TO BE PERFORMED: <br /> NEV`WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) [I DESTRUCTION(choose type below) <br /> SOIL BORING#1 0 OVER-BORE <br /> SOIL BORING <br /> 0 PRESSURE GROUT <br /> `Other: Grout Specificadons: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> `MONfTORING FIOLLOW STEM DIA OF BOREHOLE If /S fr MULTIPLE CASINGS?[I YES 40 WELL CASING OW <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS D TYPE OF CASING: D STE`EEL )C/C g OTHER: <br /> []VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Q' S TREMIE TYPE TO BE USED: -4AUGER5 a HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes )rb (NOTE. 1M/UIIA FR^ -E-FALL DEPTH 1$341 <br /> 1]SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: _ ((\\_ <br /> 0 OTHER Fl OTHER APPROX BORING DEPTH a.0 r 0 BOLTED TRAFFIC SOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPME07 .11M (if YES,list spedfications 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 Re Iatlons, applicable California State Laws. <br /> Signed x J TitlelCompany <br /> Print Name ' I{ Date C/-q A),�,�_„ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FILE,ADDRESS: <br /> WORK PLAN DATED: 3a.war OU 1 <br /> Application AcrPpted By C. 4' � Date Issued " - Z""�srea <br /> Grout Inspection By Date Final Inspection <br /> Destruction Inspection By Date <br /> COMMENTS l CONDMONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'O BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> � <br /> C-57_ WC_-WATVERC-57 Letter of Auth iza on to sign permit—Encroachment doc� 1/25/02 <br />