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WELLIERMIT APPLICATION FOM 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 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department.Assessor's _6Z <br /> 4Z� N I/A,( l u / 'Cross Street A City ST��l rT Zip Parcel# <br /> WELL Location /�/ > / 7_87'// <br /> PROPERTY Owner Ll TV �� /��r fl_] Address N- �� D & CitysLOCILT�/ Zip S9�z Phone# �3 <br /> tyS>A�C .—Zip Lic# <br /> C-57 Contractor til,tc�lu /�L{/LJ��+'Address' L/,Gc S(-'r wA77,/FYVf Ci / �S�ZZ) ',/a �� <br /> A ,Ct�, Address a�7 �t1 nW ' City L�eTuti Lic# Phone# <br /> Consultant/Sub Cntr - <br /> Y ,Township_—Range Section <br /> GIS Coordinates:X ��`� <br /> WORK TO BE PERFORMED: D <br /> 0 NEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) LLLLESTRUCTION (choose type below) <br /> OVER-BORE <br /> 0 SOIL BORING# p/ ry7 PR SURE GROUT <br /> 0 WELL# <br /> Grout Specifcations: <br /> `Other: <br /> COMMENTS JQ D VU 611b <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 MULTI-LEVEL?0 WELL CASING DIA:_ <br /> TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> ROTA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL <br /> 0 AIR SPARGE/Ozone 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> p SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> p OTHER: 0 OTHER APPROX.BORING DEPTH D <br /> CONDU/pTOR CA(g/ING <br /> PRO ( f YES.listpcetion$here): <br /> "COMMENTS: LL S c �_ S / <br /> l <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 Ordina s,rjle nd gulations, and all applicable California State Law/s. 1 J <br /> Title/Company A �T r� L-ifa <br /> Signed X <br /> Date <br /> Print Name &/ }-4—�- DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: pT C 1202 <br /> CW Date Issued / � W Area <br /> A rout Insp Accepted By t 0 Date <br /> Grout Inspection By <br /> �; Date final Inspection By <br /> Destruclion Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# C' BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> /0 la Z I <br /> 8/29/02 <br /> = <br /> C-57_ WCWAIVER_ C-57 Letter of Autho izI'tio o sign permit_Encroachment doc_ <br />