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OPYu _ l <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA. , 95202 <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 and/or install the work described. This application is made in compliance with San Joaquin County <br /> Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> / (")g /',/' ,40�_ MOP <br /> OP Assessor's <br /> WELL Locationl�[[I ��Ja ' ��D�� y ! • <br /> Cross Street City Zip /JL✓r� Parcel# / �7— Z� � 03 <br /> PROPERTY Ownerfy__��T Zr Addressl2✓1 ? C&IJU 5T99 City51UL..l�p-Telh[ Zip�_Phane# '7�ldv <br /> C•57 Con1ractorV�ST F�dZw�ltArr7 Address 1 ity�Z,,i��p��t''5��2,. �Z Lic#2ftPhon J -� ( � <br /> Consultant / Sub Contractor� •l.f.G' <br /> Address Ltl CityjS d1J iO� PhoI <br /> GIS Coordinates: X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br /> 0 OIL BORING # 0 OVER-BORE <br /> W ELL # M - M W S 0 PRESSURE GROUT <br /> 'Other: T- � Grout Specifications: <br /> COMMENTS: <br /> ```T��'YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I�MONITORING 'dHOLLOW STEM DIA. OF BOREHOLE ?i <br /> ,_�� 'MULTIPLE CASINGS? 0 YES �(Fl0 WELL CASING DIA: 2,rrr - •, <br /> 0 `EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESSSCW, � TYPE OF CASING: O STEEL O PVC KOTHER: j JDA <br /> 0 VAPOR O MUD ROTARY DEPTH OF GROUT SEAL ZO 1 TREMIE TYPE TO BE USED: 'AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes K_No (NOTE: MAXIMUM FVEE-FALL DEPTH IS 30')yyM <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: VA <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH �0 r - 1BO`LTED TRAFFIC BOX or 0 STOVE PIPE <br /> pp�� <br /> CONDUCTORCASING P,{R�O�P�OSED? a ( if YES, list specifications here): <br /> 'COMMENTS: 7114 O ! LOD AtUL7( � n4l& -�f� j4W/ [OIfAL/� &`IEaC <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS, <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> Rules and Regulations, andel alba plicable California State Laws. <br /> Signedx1/ 2 - %[ Title/Company !�TAFF �T& lCer3rlAbVAaitE rTL61JV LA1M"(7w4L <br /> p — �/ <br /> Print Name �n�t(4 (�. ,LJ\ D7�6' Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : � '0 <br /> WORK PLAN DATED : <br /> Application Accepted By `-� Date Issued <br /> r A ' <br /> Grout Inspection By Date Final Inspection By I t0 — <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PECODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 34O ZOL7 � SR# Q/DJb 62 - <br /> C-57- WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ 1/25/02 <br />