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FILE COPY <br /> WELL PERMIT APPLICATION FORM SITE <br /> �- SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) t UNIT w <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 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department- <br /> (f „ Assessor's <br /> WELL Location 7 �ci Y�YG� �l�fy" � Cross Street�1�11 Cit4hI ^^ ZIp1S Z1)� Parcel# <br /> PROPERTY Owner Y�" i f1k � Address 7 � l�A�ti fy �f City='���l�tip � ho e#y <br /> C-57Gontracto 11S Address/_'7c� �ldW� PM— City J�k'i?,Lzip `f '�iiaF-( 7PhoneW; <br /> Consultant!Sub CntrT= f7��C Address t/tA tai L City) c[[�[{t�lic# Phone#W I Vb IL 00(D <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED• <br /> EW WELL/BORINGCPT EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> 1]SOIL BORING# OVER=BORE <br /> [I WELL# p PRESSURE GROUT. <br /> 'Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING [I HOLLOW STEM a DIA.OF BOREHOLE �'S MU LE CASINGS?(]MULTI-LEVEL?U WELL CASING DIA: <br /> 1]EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS' AIA- 1 y,fZ TYPE OF CASING: I]STEEL [I PVC a OTHER: <br /> 0 VAPOR q MUD ROTARY DEPTH OF GROLYr SEAL i5r7b TREMIE TYPE TO BE USED: []AUGERS a HOSE <br /> II AIR SPARGE I OzoneAfUSH POINT GROUT SEAL PUMPED: des 0 o (N E: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING [I HAND AUGER GROUT SPECIFICATIONS: )9 ' <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 1.30 FbV_�, 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING NPOSED?_�_(if YES,list specifications here):'COMMENTS: rn dC S`E <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 <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company C7)/=7� r0IL <br /> Print Name IY1/ I Dale l Z� /z� _ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: I :� <br /> Application Accepted By Date Issued_ Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE-:----,!- PERMIT J SERVICE REQUEST# INVOICE <br /> o 1;L016 <br /> ? b; <br /> C-57 WC -WAIVER C-57 Letfer of Authorization to sign permit y1f Encroachment.doc k 8/29/02 <br /> i <br />