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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 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joe uin County Environmental Health Department. <br /> `1 ii ,,I Assessors <br /> WELL Location-4)'1 C�e-(01�,o— Cross Street 0. City LoU f_ Zip Parcel# <br /> PROPERTY (` 11 P.) Ir � 90f QIu, City �O�t Zip Phone#—(03" <br /> Owner�' nMl" I f(f�G 1 Address -"" n - ' 'e G <br /> C-57 Contractor 1 t !.J Address Io� ��2M��(11•iwz �1.-r1CHy c��.,�A�L,Q, Lic# 014on �? <br /> Consukant/Sub Cntr � � Address�� clry X13 Wo-4 Lid/ h 6)Aar Phone# <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 /> a SOIL BORING G# OVFR-BORE. DIAMETER <br /> # <br /> RESSURE GROUT <br /> Other CIEJSAIIO <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING "HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_TYPE OF CASING: U STEEL VC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_ -tj)_TREMIE TYPE TO BE Ui XAUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROLTT SEAL PUMPED: 0 Yes 0 No`(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> f tL <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS PI D f <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH�� a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord' res !: d ReguI Bron nd all applicable California State Laws.`, <br /> Signed x Tide/Company -- <br /> Pnnt Name -T �"L "'7�-1 Date��TUt1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: ee { rte] <br /> Application Accepted By 4 ....a A . .1 .I r� Date Issued O Area T / �dr <br /> Grout Inspection By Dale Ymo Final Inspection By 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 I SERVICE REQUEST# INVOICE <br /> 20Z Dy SR1100� <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />