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RIS mvm <br /> APIA $ Zp3 WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY TION <br /> � <br /> NVIRONMENT HEALTH ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT MITIGATION <br /> ' PERMIT/SERVICES 304 E Weber, Third Floor, Stockton, CA , 95202 <br /> IV <br /> S- fro_ <br /> (209) 468-3449 Co <br /> ` NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I <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 Countyevelopment Tile Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> Assessors <br /> WELL Locatia h+r N 4Ar (r ross Street d City C Zip Parcel# <br /> ' PROPERTY <br /> Owner r ��ress !D p /���6 oh, 4-,V1 p f Phone# <br /> C 57 Contractor lr6At C Addres&e,Z/ Ci A OZip� t ic#/U�l�r Phane#�✓� E C;�-7b � <br /> ' Consultant!Sub Cntr Address City -Lic#_jj h— e4 M�'�/ <br /> GIS Coordinates X 'y Township Range Section <br /> ' WORK TO BE PERFORMED <br /> 0 NEW WELL/ BORING (CP E P DROPUN HAND-AUGER OTHER-) RUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER BORE DIAMETER <br /> a WELL# 0 PRESSURE GROUT <br /> ' O'Other GROUT SPECIFICATIONS <br /> M ENS <br /> 114 All <br /> t TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING 0 HOLLOW STEM DIA OF BOREHOLE -Z —p MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS N TYPE OF CASING 0 STEEL 0 PVC 0 OTHER <br /> Iva VAPOR (I MUD ROTARG-9rCPT)GROUT <br /> DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 0 AUGERS Q HOSE <br /> 0 AIR SPARGE!OZONE�PUSH POIN SEAL PUMPED 0 Yes 0 No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> ' SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 4 600Q— — <br /> ()OTHER a OTHER APPROX BORING DEPTH 26' _ a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES test specifications in comment section) <br /> COMMENT$ <br /> ' NOTE OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> ' 1 hereby certi at I haV pre red this application and that the work will be done to accordance with San Joaquin <br /> Ord a c <br /> County es s a Regulations, and all applicable Califor State Laws <br /> Signed x Title/Company �� (� <br /> Print Name Date <br /> DEPARTMENT USE ONLY o IC 1`�i <br /> r r / ,, <br /> ' SITE MAP IN UNIT IV FILE, ADDRESS (�-11 3L.A <br /> WORK PLAN ELATED ' <br /> Application Accepted By 5- 64Date Issued �r l �3 t-Atlttl�llesn �a L <br /> ' Grout Inspection 8 1 Date Final inspection By nrr ` - <br /> Destruction Inspection By Date ii <br /> 71 <br /> COMMENTS I CONDITIONS e- <br /> YPEO <br /> G ONLY AID# FAC# <br /> ' FEE INFO AMOUNT REMITTED CHECK# REG D 6Y OATE PERMIT I SERVICE REQUEST# INVOICE <br /> � .1 <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doe_ 9/30/02 <br />