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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 PATE 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 /> f� 4. Assessors <br /> WELL (Ai <br /> Location _ ` u)`- T-6t'f4itl�Cross Slreel City Zip Parcel# <br /> PROPERTY `` c, 2 �7 <br /> Owner Address G t - C+ty_ Z+p�J.7(�66 Phone# 3j t" p q�TT r <br /> C 57 Conlracsor Address liJi.t FL Ciiy Zip Lic> Phone# 2,r31.7–Consultant I Sub Cntr ' t Address 2[525 F. N V 14P. City Lich! Phone a -/3 7 J <br /> ' GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED // <br /> G NEW WELL I BORING (CP GEOPR08 HYDR PUNCH HAND-AUGER OTHER-) ' DESTRUCTION (choose typ?b jw) ,r <br /> G SOIL BORING# t Z J� G vER-BOREl91P.tKEETER ti / >_____�2 <br /> G WELL# G PRESSUR ROU <br /> G'Other r GROUT SPECIFICATIONS <br /> COMMENTS <br /> gcLd <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING G HOLLOW STEM DIA OF BOREHOLE Q MULTIPLE CASINGS G MULTI-LEVEL WELL CASING DIA <br /> �GEXTRACTION G AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING G STEEL G PVC G OTHER <br /> Q VAPOR G MUD ROTARY DEPTH OF GROUT SEAL �J TREMIE TYPE TO BE USED GAUGERS Q HOSE <br /> G AIR SPARGE/OZONE*USH POINT(GP or CPT)GROUT SEAL PUMPED G Yes G No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> ' G SOIL BORING G HAND AUGER GROUT SPECIFICATIONS iV ,d_— <br /> Q OTHER G OTHER APPROX BORING DEPTH , ) G BOLTED TRAFFIC BOX or G 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 certifyI have prep red this application and that the work will be done in accordance with San Joaquin <br /> County Ordln �F6s an Regulations, and all applicable Caltfornla tate Laws <br /> Signed x TitWCompany /cl �� a-06r f rlVc�-IltiWu4�1 <br /> ' Print Name 6Date OO <br /> DEPARTMENT USE ONLY <br /> ' SITE MAP IN UNIT IV FILE, ADDRESS , <br /> WORK PLAN DATED '! <br /> Application Accepted By Dale Issued__ YlgZ03 Area <br /> Grout Inspection By 0 Hate Final Inspection By Date <br /> Destruction Inspection By Date <br /> ' COMMENTS I CONDITIONS L t r d 4 rJ lit Q r <br /> ECGOIINTING ONLY AID# FAC# <br /> ' FEE INFO AMOUNT REMITTED CHECK# REC D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> SR# 333 <br /> 1' `G-57— WCC WAIVER— C-57 fetter of Authorization to sign permit_Encroachment doc— 9/30/02 <br />