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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 Joaquin County Environmental Health Department. <br /> C S ross Street ` L1City f � Zip Assessors <br /> WELL Location I IDno n2I1L� <br /> Parcel# <br /> OOwneERT � Address IID LIAQ-f 0 City L�� Zi Phone# <br /> C-57Contractor (� Vt�l�i/., Address �t -Cdr: ,�` itytSl�"' ~✓ �P"OV'�Lic#ID /ab(Phone# 4�63)-3�d�' <br /> Consultant/Sub Cntr r \ VI� Address ^�02)-7 M' � city20kkkic# 3" Phone#a6l 7',Jb7-16b <br /> GIS Coordinates:X ,Y Township Range Section <br /> ORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) D DESTRUCTION (choose type below) <br /> SOIL BORING# D OVER-BORE. DIAMETER <br /> WELL# `� D PRESSURE GROUT <br /> D'Other GROUT SPECIFICATIONS_,pd7_i_I �L <br /> COMMENTS: <br /> PE OF WELL IN TALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> (� MONITORING HOLLOW STEM DIA.OF BOREHOLE D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL VC`' D OTHER: <br /> ���.Drrr'VAPOR D MUD ROTARY DEPTH OF GROUT SEAL��TREMIE TYPE TO BE U� HAUGERS D HOSE <br /> IPAIR SPAR E/OZONE D PUSH POINT(GP orCPT)GROUT SEAL PUMPED: D Yes D No1(NOTE: MAXIMUM FREE-XLL DEPTH IS 30') <br /> D SOIL BORT D HAND AUGER GROUT SPECIFICATIONS RfhYl <br /> D OTHER:_a OTHER APPROX.BORING DEPTHD BOLTED TRAFFIC BOX or D 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 I have prepared this application and that the work Will be done in accordance with San Joaquin <br /> CountyOr ' es, ule d Regulati -n,,,S,..and all applicable California Stat IL <br /> Signed x Title/Company - <br /> 9 <br /> Print Name 4 Dale �f� A <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By r//od'1C wtiB'C.t" - / Dale Issued d Area <br /> Grout Inspection By Date_ Final Inspection By Date <br /> Destruction Inspection By <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FqC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> a4. S1- 561 sR# 003-7 S-tt <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />