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i <br /> 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 descnbed This application+s-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 /> Assessors <br /> WELL Location0b-A�-� Z-� 40 Cross Streel FCity Zip Parcel# <br /> PROPERTY J p p <br /> Owner �I Address 4 r City.S zip 1ZC Phone# �3-�' fJ �A 7- <br /> CG <br /> C 57 Contractor C f, %X Address_ l lU K G+ly Zij��Uc Phone# Z�31 3—6P <br /> ' Consultant!Sub Cntr l` p f Address Y 6 <br /> 225 y _ Cily Ilse# Phone o �f 3 <br /> GIs Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/ BORING (CP GEOPROB HPDR PUNCH HAND-AUGER OTHER-) ESTRUCTION (choose typF bel�w) <br /> SOIL BORING# i 1 Z N c]� VER-GORE .Q"ETER <br /> G WELL# G PRESSUR ROU <br /> 4'Other GROUT SPECIFICATIONS <br /> COMMENTS L-JI 13JE1 At� A. <br /> 1 r <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> G MONITORING a HOLLOW STEM DIA OF BOREHOLE'_ G MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> 0 EXTRACTION G AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING G STEEL 0 PVC 0 OTHER <br /> 0 VAPOR G MUD ROTAPY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED GAUGERS a HOSE <br /> G AIR SPARGEI OZONE�i-PUSH POINT(GP or CPT)GROUT SEAL PUMPED O Yes a No (NOTE MAXIMUM FREE-FALL DEPTH 15 30') <br /> G SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS LIC + (�nlG�,1 <br /> G OTHER a OTHER APPROX BORING DEPTH 25 Q BOLTED TRAFFIC BOX or G STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (it YES hit specifications in comment section) <br /> COMMENTS <br /> NOTE OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> i <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> ' 1 hereby certify. I have prep red Chis appltcatlon and that the work will be done In accordance with San Joaquin <br /> County Ordfn e Es an Regulations, and all applicable California tate Laws <br /> Signed x Title/Company Ir ffcF <br /> Pnnl Name tr Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT 1V FILE, ADDRESS _ CL<-k <br /> WORK PLAN DATED 0 <br /> /! t <br /> Application Accepted By Date Issued 7 `ref Area <br /> Grout Inspection By Dale Final Inspection By Dale <br /> Destruction Inspeclion By 1 Dale <br /> COMMENTS/CONDITIONS L t r d Q do rp <br /> 'r ACCOUNTING ONLY Alp# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> �C SR# <br /> ' C-57— WC -WAIVER C-57 Letter of Authorizatton to sign permit Encroachment doc____ 9/30/02 <br />