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WELL PERMIT APPLICATION FORM <br /> SAN JOAQUIN COUNTY <br /> CIT ENVIRONMENTAL HEALTH DEPARTMENT (EHD) OCT TTIPATION <br /> Weber Third Floor Stockton CA. 95202 �IT '� LTH <br /> Rb (/(� 304 E. , ENVIR�IMFPJ I F�t�, <br /> (209) 468-3449 PER�A j/SERVK tb <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 Standard,^r Can.Ioaauin County Environmental Health Department. <br /> �/ _ (� •� Assessor , <br /> WELL Locatio 0'tT� r A:e•v�Z�(� ross Street r t��^ AC y Zip 9�3��o Parcel#— -- <br /> f <br /> PROPER'ry Gr / Y <br /> Owner _• Idress 52o Trocy 31yo1. C;ty-(acr zip f537t; /Phone# (2-0 7) 73/-y60U <br /> C-57 Contractor&r,,g l Dr,l04d•Te51;/'jAddress'750 HOWC KoaZip 9'1553Lic#y95165 Phone#0 20313-S Yoo <br /> Consultant/Sub Cntr SA iC Address 32- wa?f AVe,Ste Zto City$ *A Ano,Lic# L�A Phone#(q/(.)971f-•8800 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORM <br /> `JNEW WELL ORING (CPT,rGnPROB HYDROP.UNCN,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> SOIL BO # 5B—1 £ SS-2_ 0 OVER-BORE. DIAMETER <br /> WELL# 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: Sec SA IC_ I.JoaKPLA,NJ DAD 7/31120°3 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE �,/ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:r//� <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS AIA TYPE OF CASING: a STEEL Q PVC p OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL e_ k aF b r,�j REMIE TYPE TO BE USED: 'aAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE )(PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes )(No (ROTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS NCO+ Cevrteh�" roof <br /> 0 OTHER:_[I OTHER APPROX.BORING DEPTH 15 -f+ bas 0 BOLTED TRAFFIC BOX or G STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NA (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O�rQd/i� nces, Ru es and Regulations,and all applicable California State Laws. 1 1 SA C <br /> Signed x <br /> G"' G� '�bwc Title/Company f a�f Sc i e r}"//57 <br /> V !'�1 S'lou/Ir� /o 127 03 <br /> Print Name V' tDEPARTMENT USE ONLY Date <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 03 <br /> Date Issued Area <br /> Application Accepted By 1 <br /> Grout Inspection By Date Final Inspection 7, -� Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �� SR# ba5911 <br /> �� C-57 Letter Authorization to sign permit_Ener nchment do 9/30/02 <br /> C-57 WC -WAIVER_ �03.�� <br />