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OR16INAL <br /> I <br /> WELL PERMIT APPLICATION FORM SITE <br /> O ECEND SAN JOAQUIN COUNTY MITIGATION <br /> 41V ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> S p fl 2403 304 E. Weber, Third Floor, Stodkton, CA., 95202 CGPIF5 <br />' ENVIRORMENT HEALTH (209) 468--3449 <br /> PERMIT/SERVICES [YON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C05 ~' <br /> lrcahon is hereby made to San Joaquin County for a permit to construct and/or instail the work described This application is made in compliancewith San <br /> kapquiri County Development Title,Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> YELL Location 12 O W.I son —W-&-y—cross Street arI r* city S+oc,K,+o� zip 9S_ a o 2 Parcel# -,g p b <br />�ROPERTYOwner 1$ L) 5iCC, -t6AJ Address ZS N: �W-Ofb- �� N Zip <br /> -57 Contracts &ixt IN &-ru- �Address 95 D S&I-+C 1� aclty� Tipq�j�j�ic�p�i�,4�'hone#gz5 31�5 f 0� , ,ca <br /> w p nn c. a <br /> lansultant/Sub Cntr £ Address 0 3 Sha,.J rSC City S+p�K fs�tLsc#�c Sd.�2 _Phone# '�C 7--LOO Ca _ <br /> X15 Coordinates X 3 7 q6 ja`i Z ,Yy ti z I .�s os3 ,Township Range Section <br /> RK TO BE PERFORMED <br /> EW WELL/BORING(CPT,GEOPROBE,HYDR PUN C HAND-AUGER,O ER`) ❑DESTRUCTION(choose type below) <br /> BORING#_C T= r C-P T- OVER-BORE <br /> 10"t [I WELL# p PRESSURE GROUT <br /> er Grout Specifications <br /> rF <br /> OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIDNS <br /> ?� WELL CASING DIA <br /> NITORING a HOLLOW STEM DIA OF BOREHOLE_MULTIPLE CASINGS?I7 MULTI-LEVEL <br /> ] EXTRACTION 0 AIR HAMMERIORIVEN CASING THICKNESS N/ A TYPE OF CASING 0 STEEL U PVC 0 OTHER <br /> 0OR 0 MUD ROTARY DEPTH OF GRc)Lrr SEAL T TREMIE TYPE TO BE USED []AUGERS ;g HOSE <br /> fPARGE/Ozone XPUSH POINT GRoLrr SEAL PUMPED ,Yes 1]No (NOTE MAXIMUM FREE-FALL.DEPTH 15 301) <br /> X'SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS TQ To <br /> OTHER D OTHER APPROX BORING DEPTH I Z.O [1 BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?--NA a,f YES,list specifications here) <br />(OMMENTSLl born$',& v� OCrl1 per ,jca4,oy% I G T C- C I S <br /> a 4 ouh �}ar 5 ar-r I S <br /> DOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Lhereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> ounty Or s, Rules a Regulations, and all applicable California State Laws. p <br /> igned x TitlelCompany B n o r df ear# 4Caenn i f►i'le n�a <br /> not Na <br /> Date 1 O <br /> DEPARTMENT�U/S�I EQ,O,�N,,LY <br /> ITE MAP IN UNIT IV FILE,ADDRESS: VA-27 <br /> / • �"' <br /> 5 <br /> WORK PLAN DATED: � 9 <br /> pfication Accepted By Date issued d�` Area Q <br /> Grout Inspection By Date Fnal Inspection By Date <br /> estrucdon Inspection By Date <br /> COMMENTS/CONDMONS <br /> OUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 13ERVICE REQUEST# INVOICE <br /> -�� <br /> C-57 WC--. WAIVER C-57 Letter of Authorization to sign permit En$c�r�e menti dos 8/29/02 <br />