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• • FILE COPY <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ►( 1 " i 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 29 5:;v <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made 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 and1he Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> / rr.. , a `'Q' Ln01 zip 95x95 Parcel# 055`3a .. <br /> lc Wry 6lg'r r cross Street - City p <br /> WELL Location ^ Q <br /> CIO 6;I HocA2 I[eTN 95&[ Ib f/t/5' VO <br /> PROPERTY Qj Q Ciry S n Zip / Phone# <br /> Owner Nil wP'ST PEjtolQ.pn, Address /$ S+i Crn b 9S7`iz ,717110 rrp <br /> C-57 Contractor <br /> <ASC,l�JG /�f!)II nS Address 31a3a ONEC Ci7C�City aP � ZiP Lic# Phone# <br /> p �'i7 SHAwRD city STcclfrad.ic# (o o2Z Phone# 7o3f y -/per <br /> Consultant/Sub Cntr R �U• Address <br /> GIS Coordinates:X ,Y <br /> Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION (choose type below) <br /> v(NEW WELL I BORT G GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') a OVER-BORE. DIAMETER <br /> a SOIL BO NG# 0 PRESSURE GROUT <br /> `WELL# - ` GROUT SPECIFICATIONS <br /> a*Other .--1 1 QT C VM Z n �C <br /> COMMENTS: d' 7S oy-oE�'r Zz3 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Zif <br /> AE ONITORING -IOLLOW STEM DIA.OF BOREHOL0 MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: <br /> /� S�hcD�14 <br /> p EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS y TYPE OF CASING: 0 STEEL PVC OTHER: <br /> � <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 3' TREMIE TYPE TO BE USED: O AUGERS ^R�HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes <br /> s �No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> HAND AUGER GROUT SPECIFICATIONS r f r D 7-1 0� "— <br /> p SOIL BORING O BOLTED TRAFFIC BOX or O STOVE PIPE <br /> p OTHER-0 OTHER CONDUCTOR <br /> .BORING DEPTH S O D <br /> CONDUCTOR CASING PROPOSED /V D (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�nances, RUI s and Re ulations,and all applicable Californla7y�Q7tate Laws. <br /> mpany / x 1 /� / F <br /> Title/Cori fl/OS lYI / Cr <br /> Signed x 1 <br /> T v�///}R Ot/ rJo � <br /> P C <br /> Print Name DEPARTMENT USE ONLY Date '0 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: —1 -0 <br /> Date Issued e Area <br /> Application Accepted ByE'y ,i', ,. <br /> Grout Inspection By Date Final Inspection By <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 I SERVICE REQUEST# INVOICE <br /> 790 54 � �v042� C� -g- sR# o03 1190 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_EncroaaQchcmrent doc_ 9/30/02 <br />