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1 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT 1V <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 appitcabon is made in compliance wiih San <br /> Joaquin County Development Title,Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> II�'' Assessors <br /> WELL Location `l �1�U� S-5 4o LO(S )►� Cross Street FA1k IA City Zip Parcel# <br /> ' PROPERTY r c, <br /> Owner C 5 Address r Crtys Ziip!&C Phone# <br /> C-57 Contractor_ 1 r, % Address'��o �___FCCity - Zip2ff3 Lic#�Phone# 2 313-� <br /> ' Consultant I Suis Crit r � I, Address2[32� CC__L�N,V A� City,, A L,c# Phone +13 f <br /> GIS Coordinates X Y Township Range Section <br /> ' WORK TO BE PERFORMED <br /> 0 NEW WELL I BORING4(CPGEOPROB HYDR PUNCH,HAND-AUGER OTHER') DESTRUCTION (choose typ?be�w) �r <br /> a SOIL BORING# I Z NJ� VER-BORE ETER —'Z r <br /> 0 WELL# a PRESS UR ROU I/7_ <br /> ' a*Other r GROUT SPECIFICATIONS <br /> COMMENTS <br /> A4 G <br /> ' TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING G HOLLOW STEM DIA OF SOREHOLE_Z:_ G MULTIPLE CASINGS ©MULTI-LEVEL WELL CASING DIA. <br /> Q EXTRACTION Q AIR HAMMERIORIVEN CASING THICKNESS ---- TYPE OF CASING a STEEL a PVC a OT14ER <br /> EA <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SL dJTREMIE TYPE TO BE USED GAUGERS a HOSE <br /> p AIR SPARGE/OZONE-Ir USH POINT(GP or CPT)GROUT SEAL PUMPED a Yes a No (NOTE MAXIMUM FREE-FALL DEPTH 15 30') <br /> ' a SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS 1V _ <br /> a OTHER a OTHER APPROX BORING DEPTH a BOLTED TRAFFIC BOX or Q 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 OrdtnA e s an Regulations, and all applicable California /`tate Laws <br /> Signed x TaWCom .__.Ive."ItfiW- kpany /U�� af <br /> ' Print Name Date <br /> DEPARTMENT USE ONLY <br /> ' SITE MAP IN UNIT 1V FILE,ADDRESS. , <br /> WORK PLAN DATED- 0 <br /> ' Application Accepted By Date Issued `t �� Area <br /> Grout Inspection By pate Final Inspection By Date <br /> Destruction Inspection By Data <br /> ' COMMENTSlCONorriONS LtMr d O "0 t0 2r <br /> ACCOUNTING ONLY AID# FAC# <br /> ' PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> S R# 333 <br /> C-57_ WC� WAIVER C-57 Letter of Authorization to sign permitEncroachment dac_ 9/30/02 <br /> i <br /> Y fir' <br />