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i <br /> LA� WELL PERMIT APPLICATION FORM <br /> pIn SITE ' <br /> �p1 .1 SAN JOAQUIN COL NTY MITIGATION <br /> ENVIRONMENTAL HEALTH DE ARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Sto kton, CA., 95202 <br /> (209) 468-344 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install t e 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 C unty Environmental Health Department. <br /> Z L!L(cj WeS-r fG� T 7L� LO.6TZ S',cc � 1 Assessors <br /> WELL Location L-a P-4E Cross Street City Zip Parcel# <br /> 5:A cw 6s r'47c0 '177 b— 04 FF M! 014y6L O&CVO felIA L✓V(17 _ <br /> PROPERTY O»r� L_L-C Address Is vrrz� City C'�V— Zip� �Phone# 10S 7d8 6053 <br /> Sr5'/2Z6 '07(4r �vl< S YON Zi �r'�2°�Lic#�`-/Z2bSone# rf6��71Z <br /> C-57 Contractor c�J Address Ci p <br /> Consultant/Sub Cntr y�fy�ddress City Lic# S7j0 7 Phone#gf? 70? 5 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 VER-BORE. DIAMETER <br /> 0 W ELL# RE55URE GROUT <br /> 0*Other GROUT SPECIFICATIONS Lir <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING (4) 0 HOLLOW STEM DIA.OF BOREHOLE3rG rZ+0 M LTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS _ TYPE OF CASING: 0 STEEL I]PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1 1� TREMIE TYPE TO BE USED: 0 AUGERS XHOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: []Yes 0No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS N ArT G€-11 C=am <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> ! CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: C� C "c a. - 61nx-t 1 r-e-) Z M3 �- 0--s-. <br /> NOTE: OFFSITE BOR GS REQUIRE ACCESS AGRE EMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that thew rk will be done in accordance with San Joaquin <br /> County Ordinances,jtules a d Regulations, and all applicable Cali ornia State Laws. <br /> Signed Title/Comp ny <br /> Print Name <br /> ICH IQ L—. VVL a 6-0.4 Date 9/Z'r d� <br /> DEPARTMENT USE: ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED:. <br /> ! • --1 1-005- <br /> Application <br /> -0v5- <br /> Application Accepted BDote Issued_ Area 997 <br /> Grout Inspection By Date Final In pection By Date <br /> Destruction Inspection By Date p <br /> COMMENTS/CONDITIONS: 2 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PEE COPES FEE O AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT IS ERVICE REQUEST# INVOICE <br /> 3S.o3 '9sQ 3 a� 03 ! *fay Df SR# 40cI 0A, <br /> C-57 WC -WAIVER C-57 Letter of Authorization to Sign permit Encroachment doc 9/30/02 <br /> r <br />