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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGAUNIT IV 3 NTAL HEALTH DEPARTMENT EHD <br /> � ) ENVIRONME H ( ) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 0 � 'Row <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 /> �+ Assessor's <br /> WELL Location2"Z X_ � Sln.- �/'11�_Cross StreetJ� City L G�L7�G'�--1 Zip Parcel#��y <br /> PROPERTYOwner.5431) :�►i �i� tn� Adddreess'l?(�-•� V7bL itY �k tir— Zip Phone#f//tiG .__� <br /> C-57 ContractorJ4 I Aj Address �Uu s� Ci Zip9l�Lic#,7Zosoy Phone#f;1�� 777'41drJ <br /> Consultant/ ub Contractor /4.;l;tt Address 7/0 7l1'l, Sj�- Cit l.�—Lic# Phone#/'��3TjiyA'Y <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING#_ it 0 OVER-BORE <br /> 3WELL#_� 0 PRESSURE GROUT <br /> *Other: / / i Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'MONITORING HOLLOW STEM DIA.OF BOREHOLE int MULTIPLE CASINGS?p YES 'kNO WELL CASING DIA: tk, <br /> 0 EXTRACTION /0 AIR HAMMER/DRIVEN CASING THICKNESSSGLA t1U TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL .5*�' TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: XYes 0 No (NOTE: MAXIMUM FRE&FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS:-6—RAiir <br /> 0 OTHER:_O OTHER APPROX.BORING DEPTH 75 `&BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? �� (if YES,list specifications here): <br /> 'COMMENTS: SccePA Ixl�fcuej ��e+ be-63 G � <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 tha av prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or Ina es, Ru and Regulations, and all applicable California State Laws. <br /> Signed x A Zf" Title/Company <br /> Print Name N �TU e�-1 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: z—o 2, <br /> WORK PLAN DATED: <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 ONJINFO <br /> AID# <br /> PE CODES FEAMOUNTREMITTED CHECK# RE BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> dI 612, 57 �46 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br /> �7 <br />