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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 anigaquin County Environ ental Health Department. <br /> lt. / _ Assesso I� <br /> WELL Location "l 7 S �.1AP-'�O� Cross Street /City f�fl Zip Parcel — Aa <br /> Address `� OR <br /> PROPERTY I (� �� f r Q�1„�� City 6 -r Zip Phone# <br /> Owner <br /> C-57 Contractor (y) �. Address o(gl:j i__Vn wrrrx�CkY Qa"r,� f0 <br /> Consultant/Sub Cntr ten L Address�,1)71 � City _ Lic#� a2�kone# 10/ 6610 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> W RK TO BE PERFORMED: <br /> NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') n DESTRUCTION (choose type below) <br /> ��p"L BORING# u OVER-BORE. DIAMETER <br /> SILL# I 0 PRESSURE GROUT <br /> ther GROUT SPECIFICATIONS <br /> COMMENTS: <br /> .PE OF WELL IN TALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS--Z—/ TYPE OF CASING: STEELPVC Q OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL :L j1 TREMIE TYPE TO BE USE: p AUGERS p HOSE <br /> AIR SPARGE]OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NO E: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 1I HAND AUGER GROUT SPECIFICATIONS Qbf I <br /> 0 OTHER: {]OTHER APPROX.BORING DEPTH I]BOLTED TRAFFIC BOX or a 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 /> County Or�lirfafnces Ru and R ulations, and all applicable California State Laws. <br /> Signed x �,7 Title/Company <br /> PrintName . ! ° v Date O lJ V <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: //0 p <br /> /-a— Date Issued/ O/Dy Area l9 �0 <br /> Application Accepted By , � ' A / •t �— r— <br /> Grout Inspection By14�t Dale Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACE! <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> AOL $�. — 20'2-3 Z SR# OU <br /> C-57_ W(--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />