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WELL. PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHO) L!NIT IV <br /> 394 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (2-09) 468-3449 <br /> NON-REFUNDABLE PERMfT E]CPIRES{YEAR FRt7[H t]A3 E i55LIED <br /> APPIIGatfon is hereby made to San Joaquin County for a Permli to construct andloriinstali the work described. This appiicaUon is made in compliance with San <br /> +iloaquin County 0evslopment T1Uv,C/h-apter 9-;I I S.3 and the Standards of San Joaquin County Envlrnnmentat Hesith Department. <br /> i �4CrouStrew '7'L� TT ' ��NBnCity � rd� p <br /> PROPERTY Otimer dress ! City 1 �iYv zip !l.r3-)O PRona# rf—�U f 3 <br /> } �r�-frc�C/ terra tL <br /> C37CvnlraerJr_J�� P lrfJrLt Z �p _Address 1rcY, c/1 y ad� 5!3 ,r <br /> ,�- Cif! Zp Uc# 1rPhane,. <br /> Consultant/ u0 Contravtor �! �C+� �l �f Address s��6 r/ C_Ctty • cC ?�O I ic# Phrsnek r�r-f`�� <br /> I GIs Caardlmatesr?[ .Y Township Range 5ecdon <br /> WORK TO HE PERFORMED: <br /> EW W ELL I SONNG(CPT,GE0 PROS E,HYDRO PUNCH.HANO-ALIGER,OTH1=W) V DESTAUCTI0N(wocsse type below) <br /> J [I SOIL BORING ii E]OVER-UORE <br /> f KWELL ,� 1 r 0 PRESSURE GROUT <br /> 'Other Grout Specirxaficrw � — <br /> COMMENTS: <br /> TYPE OF WELL I STALLAMON D[Eg CCNSTRUCTION SPECIFICATIONS r( <br /> )(MONITORING HOLLOW STEM DLk OP BORER QLS�� MULTIPLE CASINGS?G YES NO WELL CASING DIA: <br /> [I EXTRACTION []AIR HAMMERMRiVEN CASING THICKNESS I-Q TYPE OF CASING: 1]STEEL PVC Q OTHER- <br /> Q VAPOR []MUD ROTARY DEPTH OF GROUT SEAL 70'- - TREtdtF_TYPE TO BE USED: O AUGERS XHOSE <br /> Q PUR SPARGE Ij PUSH POINT GROUT SEAL PUMPED:XYea 17 No (NOTE: MAX]MUM FREE-/"ALL.DEPTH IS 30' <br /> B SOIL BORING 0 RAND AUGER GROUT SPECIFICATIONS: --r r Z d'v:er j rrc x5� <br /> (}OTHER: 0 OTYIER APPROX.8ORIN0 DEPTH �!5' (I aOLTED TRAFFIC SOX orASTOVE PIPE <br /> CONOUGTOR CASING PROPOSED? D {it YES,list specl15cations thereY <br /> -COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALF_THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify tt at[have }prepared this applicatian and that the work will be done In accordance with San.laaquin <br /> County Ordina esr Rules a d gula,tions, and all applicable California State Laws. <br /> Signed z r 1� TiHe/C0MPany S-rta- 6� /9 5 I I Y <br /> Print Name—_��{'�LV/5 t'S �L �/L� _ _ _ _ Dais 3 ��, <br /> DEPARTMENT LJSE ONLY �] <br /> SITE MAP IN UNIT IV FILE,ADDRES d <br /> WORK PLAN DATED: ❑ <br /> Applicadvi Accepted By _Y ' _ Date Issued <br /> Grout Inspection By Date Flnat InspecXon By Date <br /> Destrucdan Inspection By Oats <br /> COMMENTS/CONDrrION5: <br /> A.CCOUNnNG ONLY: AID* <br /> r=nr t, <br /> Pe=3Es FEE INFO AMOUNT REMf L13 CHECK-* I REC'p By DATE PERMIT 1 SERviCE REgU@ST# INVOICE <br /> .5-6 vI I sR# 73� <br /> C-57 W' -WArVER_ C-57 letter of Authorization to sign permi# Encroachment doc^ , 112 <br />