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ORIGINAL <br /> WELL PERMIT APPLICATION FORM 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 /> ��� ! ►"� I /� REFU ABLE 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 Joaquin County <br /> Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. ,q ^�, <br /> WEtio¢A L Loca /)/t�/ /S08/u I ross Street l City> Zip�5�5 Parcel ISO 0Z J <br /> PROPERTT�vrldr"r'� G ddr2es�s t1 City=s Q�Zip /J/P�hone# may/ �j� p 9 <br /> C-57 Contracto <br /> CITJ�T�I/>✓ 'Jr �t"��ddress b�(IYYtPL LTJ Cit _ZIpLic�J 1�j``Phone# /! "'3! //�` <br /> Consultant/Sub Contractor Address City Lic# Phone# <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: 3 <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION(choose type below) T <br /> OIL BORING# OVER-BORE N,,Ib <br /> WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Spe eVtions: t �� <br /> COMMENTS: V /6ttJE 'r EU) !�� Z D� OG1- f L /ku/A <br /> `TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS/xodi�A ` 4 <br /> f�MONITORING OLLOW STEM DIA.OF BOREHOLE?/-'eh MULTIPLE CASINGS?0 YES l0 WELL CASING DIA: _ ( 0 <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAQ— TREMIE TYPE TO BE USED:—e<UGERS 0 HOSE <br /> VAPOR <br /> SPARGE 0 PUSH POINT GROUT SEAL PUMPED: p-Ye's 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATION <br /> ''S,: <br /> 0 OTHER: fl OTHER APPROX.BORING DEPTH Va lk& 61� TED TRAFFIC BOX or 0 STOVE PIPE <br /> n L <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 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> Rules and <br /> Regulations,and gII applicable California State Laws. <br /> Signed x W ,� J�r�b�- Title/Company ;� NCD <br /> :,? <br /> 1'�)//l liv(� l/sf�� N ' <br /> Print Name Date <br /> DEPARTMENT USE ONLYCAMUXI <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: Z �J� CC J <br /> >G- <br /> Application Accepted By Date Issued r Area QIQw <br /> Grout Inspection By Date Final Inspection By •2fo•0-2— <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> qo M>^/ blo 3•z� SR# DOz9331 <br /> C-57WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ 1/25/02 <br />