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' FILE COPY <br /> WELL PERMIT.-APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTHUNIT IV <br /> DEPARTMENT EHD <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> �p <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 /> �b r�,� Assessor's <br /> WELL Location r I Cross Street_ e�_City S�C�.o ri zip_95Parcel# C-030-O J <br /> PROPERTY Owner FOrL O� Q-�cktOR �Addres,_E 0 (3Ox a089 �citycS`{flCc'_boK Zip ��I Phone#W f-44''n-." <br /> C-57 Contractor�pgdrum Elylom-Lory4ddress�IA6 Wjq wam Pr CitYS+01-� h zip 51o5Lic# Phone#2OQ-4(5_ 1.)_ <br /> M <br /> Consultant/Sub Cntr fit"' ConSW Address�dW�M stip St.S-k 1151 `CityFr ieS no Lic#6838 65 Phone# <br /> GIS Coordinates:X Y Township 1v Range 6 r— Secdon <br /> WORT{TO BE PERFORMED: . . * <br /> NEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) []DESTRUCTION(choose type below) <br /> []SOIL BORING# 0 OVER-BORE <br /> }-WELL# _;� 4b $ 0 PRESSURE GROUT <br /> *Other: Grout Specifications:-jr—le-4- Ce meiv+ Q r a+ y <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE Or7 G <br /> �..,..��MULTIPLE CASINGS. []YES �+10 WELL CASING DlA: .2 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL []PVC 0 OTHER: <br /> I]VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS []HOSE If <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SE=AL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS:. neat -- cE m etc4, <br /> 0 OTHER:_U OTHER . APPROX.BORING DEPTH M 0.X $D„e nA�OLTED TRAFFIC BOX or []STOVEPIPE <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 I 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. f <br /> Signed x Zj6ej L ow _ Title/Company Staff En,gi netr/deofbgis-! <br /> Print Name M I ae l Eo r, Date I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS:_ <br /> WORK PLAN DATED: !D —Z <br /> Application Accepted By Date Issued �r Z7-' 03 Area Iq W k <br /> Grout Inspection By Date Final.lnspection'By Date <br /> Destruction Inspection By Date <br /> i <br /> COMMENTS/CONDITIONS: t <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# LREC'DBY DATE ,. PERMIT/SERVICE REQUEST# INVOICE. of 3 ZyZ ' <br /> C-57 WC -WAIVER C-57 Letter of.Authorization to sign.permit Encroachment doc 1/25/42 <br /> 1 <br />