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C� ",i'\�il'_WELL PERMIT AFlPL1CATION FORM SITE <br /> R EMITIGATION <br /> JAN 0 8 2004 SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> ENVIkUNNiEN I HELI <br /> x1304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PEM,AMSERVICES (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.Assessor's 3L�, �Gl <br /> ',l.��L zip Parcel# ��� <br /> WELL Location clt y ��$ 1 d��Ylil�'L hve Cross Street f /- [ CCitLy /1� P <br /> l k UwCCf J ` City / lk v�P��L Z;p `�s33 Phone# a39' <br /> PROPERTY Owner �l �� e��l Address �- <br /> City zip ' Lic# Phone# <br /> C-57 Contractor Address �7 r /(� ,�,( >0Q <br /> I fit' ��Q-Y Address <br /> o�g S City �""�� Lic# Phone# <br /> Consultant/Sub Contractor /L F-6 <br /> GIS Coordinates:X ,Y <br /> ,Township Range Section <br /> i <br /> f <br /> PIEW <br /> K TO BEP ED: ; DESTRUCTION(choose type below) <br /> WEL /BORING CPT,GEOPROBE,HYDROPUNCH, AND-AUGER OTHER') OVER BORE <br /> SOIL BORING# l-�L PRESSURE GROUT <br /> 0 W ELL# rout Specifications: <br /> *Other: <br /> COMMENTS: <br /> TYPE INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?DYES ONO WELL CASING DIA: <br /> AIR HAMMER/DRIVEN CASING THICKNESS TY OF : 0 STEEL 0 PVC 0 OTHER: <br /> EXTRACTION 0 DEPTH OF GROUT SEAL E TYPE TO BE USED: D AUGERS a HOSE <br /> 0 VAPOR Q MUD ROTARY <br /> PUSH POINT Yes�lro (NOTE: MAXIMUM � LL DEPTH IS 30S <br /> 0 AIR SPARGE GROUT SPECIFICATION ' �� <br /> SOIL BORING ,,HAND AUGER CONDUCTOR CASING PROP�S�APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or 0 STOVE PIP <br /> D <br /> 0 OTHER:__0 OTHER if YES,list specifications here): <br /> /�� � ( <br /> 'COMMENTS: / V0�! V W <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OCE CROACALL RHMENT OU RED IN MI TSI. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN AD <br /> hereby certify that I have prepared this application <br /> applicable ndtthe work will <br /> be done in Laws. accordance with San Joaquin <br /> County Ordinances, Rules and Re ulations, andS�k1�� G� �P�� <br /> �� �i(` Title/Company n y <br /> Signed x / / <br /> PQ Date <br /> Print Name DEPARTMENT USE ONLY <br /> �GI/112 ,�c.. <br /> SITE MAP IN UNIT IV FILE,ADDRESS: C;1�J <br /> WORK PLAN DATED: <br /> Date Issued <br /> „. '.: :: ,:- ;Area <br /> Application Accepted By Date Final Inspection By Date <br /> Grout Inspection By Date <br /> Destruction Inspection By <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# rare <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> l ) g 'l-9 SRU LZ /0 �Z- <br /> C C-57 Letter of Authorization to sign permit Encroachment dot <br /> 1/25. <br /> C-57x' W -WAIVER <br />