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.. ', WELL PERMIT APPLICATION FORM SITE <br /> �3 SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> 02 (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 /> WELL Location 11707 t- COrISTO c< Cross Street>' Al2 K City STO CKTO"-J c�JY��s Assessor'sp <br /> Parcel# 00Zip 9-(3D-0 5J <br /> PROPERTY Owner FRF-p }CR 85 7 Address S M'F–: City Zip Phone#q31 —q 6�(o <br /> �L A ' <br /> gC-57 Contractor E//V. Address39q S)4ER's Cityy " ' 270 <br /> Consultant/ <br /> Sub Contractor 0!�ROU^VD Z�Ro Address(-71q 1,eA14 S'T. CitytsC"V0-j Lic#50,23 Phone# S38—Q"g <br /> GIS Coordinates:X 'Y Township Range 7 Section <br /> ORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYD�PUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# 0 OVER-BORE <br /> D WELL# 0 PRESSURE GROUT <br /> *Other: Grout Specifications: /yFatT" <br /> COMMENTS: ]3021-46S -(-6 ,?0 bB> <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE—q c MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi nces, Rules d Re lati nd all applicable California State Laws. <br /> Signed x Title/Company l�6 �V;Z V69 <br /> Print Name 61-2 E C O Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED//:�1�// �pn <br /> Application Accepted By AJkA--en Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> I <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> a9.0/ M " I 8q- S AVI- / oz SR# 00 S 17 3 <br /> C-57 � WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br />