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h 1 <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 i 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 San Joaquin County Environmental Health Department <br /> -r-! a Assessors <br /> WELL Location d t) -1 J -� L°C Cross Street `1441l'1A City Zip Parcel# <br /> ' PROPERTY g <br /> Owner Address r - City.s ZIP73;Z fj j <br /> C-57 Contractor t <br /> Dr% t)l Address!& JILL— FGGty �- Zip Lic#6�Phone# 3r 3�JdKJ <br /> tConsultant I Sub Critr_�`� p( Address Z city _Lic# Phone —/ V <br /> GIS Coordinates X Y Township Range Section <br /> ' WORK TO BE PERFORMED <br /> 0 NEW WELL 1 BORING (CP GEOPROB HYDRQPUNCI-1,HAND-AUGER OTHER-) J-DESTRUCTION (choose typg be�w) it <br /> 0 SOIL BORING it I ti Z N v ER-BORE ETER ti _'2 <br /> 0 WELL# []PRESSUR ROU <br /> 0'Other r GROUT SPECIFICATIONS <br /> COMMENTS f A �� W !rK4 •� <br /> s l Icy <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING 0 STEEL 0 PVC 0 OTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE!OZONE <br /> -IPUSH POINT(GP or CPT)GROUT SEAL PUMPED' 0 Yel�s 0 No (NOTE MAXIMUM FREE-FALL DEPTH 1S 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS A 0 OTHER 0 OTHER APPROX BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (ir 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 I have prep red this application and that the work will be done in accordance with San Joaquin <br /> County Ord in e s an Regulations, and all applicable California tate Laws .l <br /> Signed x TitlelCompany �U � (f <br /> � tx (�rf! <br /> ' Print Name � Date <br /> DEPARTMENT USE ONLY <br /> ' SITE MAP IN UNIT IV FILE, ADDRESS , <br /> WORK PLAN DATED ,! t <br /> Application Accepted By Date Issued `>r_J 7/,)3 Areal y <br /> ' Grout inspection By Dale Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS L t IV'►r d 4--v <br /> ACCOUNTING ONLY AID# FAC# <br /> ' PEC FEE INFO AMOUNT REMfTTED CHECK# REC'D BY DATE PERMIT f SERVICE REQUEST# INVOICE <br /> vel 4 SR# 33 3 <br /> C-57� WC---WAIVER C-57 Letter of Authorization to sign permit,Encroachment doc— 9/30/02 <br />