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' WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) MITIGATION <br /> 1 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (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 an install the work described. This application is made in compliance with San <br /> Joaquin County Development Title, Cha/pter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location-�32 / Ce.w C�� Cross SUee!/u sd,2�r,2" //�'� Assessors <br /> Sfcity c/; L Zip Parcel# %PROPERTY 6Z4-,s "j)e}t <br /> Owner_ Address City-2JT.r�j 0AJ Zip E16J/Phone# <br /> C-57 Contractor SOC cicc'ppo Address 5 7 <br /> ' /� '� `"� City cy,4,! ZiFzfSLJ) Lic#y/�G�Phone# � ^- �'/ I <br /> consultant/Sub Cntr-,IL .,a4"&6r Address�Yl /, f`7i�,g�� CityLic# <br /> Phone# <br /> GIS Coordinates:X.,Y ,Township,P Range � C� Section_ <br /> WORK TO BE PERFORMED, <br /> AIEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# <br /> ,WELL# �i 0 OVER-BORE. DIAMETER <br /> e3Z.t'" <br /> O Other G PRESSURE GROUT <br /> COMMENTS: ROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION PE <br /> 'ONI OR NG $HOLLOW STEM DIA. <br /> SPECIFICATIONS C <br /> OF BOREHOLE S MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS s>! y i�TYPE OF CASING: 0 STEEL AVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL—,21D TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes �(1No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS /1�c �f'yKE� 7/-- <br /> a OTHER:_0 OTHER APPROX.BORING DEPTH_ :!2 , $,BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED—/L� (if YES, list specifications in comment section) <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x <br /> Title/Company <br /> Print Name ,= -rL "� Date - � �/y <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Isst <br /> ' Grout Inspection By Date Final Inspecti <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ' ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DAT <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to Sign <br /> ' AMW, <br />