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WELLPERMIT APPLICATION FORM SITE <br /> •` SAN JOAQUIN COUNTY MITIGATION <br /> \� ENVIRONMENTAL HEALTH DEPARTMENT(EHD) UNIT IV <br /> V 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> ON <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 /> Assessor's <br /> WELL Location JS t�� � J• CrossStreet7 td City!�!(JG�Llyecf zips Parcel#OC)2-- <br /> ZC) e0 7 <br /> PROPERTY Owner GW S CkC.f.1•It kt Address (O k.t)Pjfcl�t()(ffL �/ City/ a rpti9Sd 9 Phone# �ZS �S`��71 S <br /> C-57 ContractorWQt7t)I+ftb (.i-W, Address SS0 �ZlUEIC City I �L _Zip/7SS7/Lic#�� 77Phone#// c) �/77`�--Y34 o <br /> aS�. C,Fis fAI✓I00. Address5� CgA-J � CityLic#� L01,2' #�Z-1y/�67`/W 6 <br /> Consultant/Sub Contractor - <br /> GIS Coordinates:X Y Township Range Section / <br /> WORK TO BE PERFORMED: �/� <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') I r DESTRUCTION(choose type <br /> RING# (0 /V•�G4r/ OVER-BOR <br /> i lJT <br /> 'Other: Grout Speci�ficaations: <br /> COMMENTS 'PfiQCtP� 4 LUC� T1 CL(� ()nl� �'c TL(�yY�17TOe.tsll�r .L� - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS *"'Ore <br /> JFMONITORING WHOLLOW STEM DIA.OF BOREHOLE 1 AI MULTIPLE CASINGS?Q YESNO WELL CASING DIA: <br /> Q EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: o STEEL Q PVC a OTHER: <br /> Q VAPOR U MUD ROTARY DEPTH OF GROUT SEAL, _TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> 0 AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: Q Yes Q No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING a HAND AUGER GROUT SPECIFICATI NS: <br /> a OTHER: ❑OTHER APPROX.BORING DEPTH 4 BOLTED TRAFFIC BOX or U STOVE PIPE <br /> �j CONDUCTOR CASIN PROPO ED? (if YES,list specifications here): <br /> 'COMMENTS: ✓ •� <br /> L70 <br /> 3'- 3 _ 2l- o <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 gulations and all ap l'cable California State Laws. <br /> Signed x G X - L� �� Title/Company A,0r1r214 <br /> Print Name ?AAL t--2>- Date 0-7 LZ Z <br /> DEPARTMENT USE ONLY <br /> -SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: O Z <br /> Ap ication Accepted By Date Issued 71-:,, <br /> r <br /> /1G out Inspection By Date Final Inspection By -3 v•�Z- <br /> yDestruction Inspection 13 ate Q <br /> COMMENTS/CONDITIONS: 4Z 4V <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> C-57 WC-j/-WAIVER— C-57 Letter of Authorization to sign permit_Encroachment do� 1/25/02 <br />