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WELL PERMIT APPLICATION FOO)�M SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 DN Mui <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. <br /> Assessor' <br /> WELL Location Z N• LIJL.lo —�"ppJCrass Street Bo <br /> �tt City 57ux4'G►..� Zip Parcel# E7U <br /> PROPERTY Owner�� , I�f�M F,IJKt�ddress ��7._E Bo d, City S17GI�Ir�.-. Zip _Phone# ! — L�oZ <br /> C-57 tractory U Address IM ��Cee,� City QS 4W Zip Lic# 209041 Phone#(U 1-1-I-Q 1.00 <br /> Consul Sub Contractor _1�u(- Address/7/q )ZI14 i cSf' City_Fy- rsA Lic# Phone# �53�5 ii i <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-)/ D DESTRUCTION(choose type below) <br /> 0 SOIL BORING# S 0 OVER-BORE <br /> `{aM/ELL# h. 46_.I L) 0 PRESSURE GROUT <br /> 'Other: 7� Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING P�iOLLOW STEM DIA.OF BOREHOLE-'k�iu MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ,IncI TYPE OF CASING 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL "90 'U TREMIE TYPE TO BE USED: `ZAUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: `KYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: NWA C^wt,x J I7Pi+n�tsu <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH `�� XBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: SC`�t�Ct IAtY�Cy4� �aQ b2Ln r 15,. o <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 ces, le and Regu�find all applicable California State Laws. <br /> Signed x / Title/Company <br /> Print Name Cy- 00 Date <br /> DEPARTMENT USE <br /> ONLY Q � <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 2<PCo 2- <br /> WORK PLAN DATED: v Z <br /> Application Accepted By Date Issued ` Area <br /> Grout Inspection By Date Final Inspection B� Date <br /> Destruction Inspection By Date ' <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R 'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> .3•x71 Oa 'Z 66,351:5.2 <br /> C-57 WC -WAIVER,_ C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br />