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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 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 JoaquinCountyEnvironmental Health Department. <br /> WELL Location IOg W, 7aSe�►i - rVe �] {�Grtx ff Assessors <br /> Cross Street City Aemmeca' Zip ys 3] Parcel# D1-0-30-63 <br /> PROPERTY Owner_ I�v2+A v.C, Address p'O1 abX' ]! City l7cr �0S,TX Zip 7S-2-21 Phone# <br /> C-57 Contractor\A-W L (-,'11 nc Address f,dCitvZSIe**'n 7ipq"41Li0-?7-0q0qPhone# 9116 777-1+]00 <br /> RgnL t\O <br /> Consultant/SubCntr SEGo2 'Tin+-ernat'FoaalAddress 3c17 IKikjr:-e,..PA City CulelGva Lic# Phone# (a(6)S°61-0400 <br /> 5 t-'e 1 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> []NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION (choose type below) <br /> []SOIL BORING# []OVER-BORE. DIAMETER C <br /> []WELL# PRESSURE GROUT —� <br /> []*Other GROUT SPECIFICATIONS 04 <br /> COMMENTS: <br /> IF- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING []HOLLOW STEM DIA.OF BOREHOLE []MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL []PVC []OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS []HOSE <br /> []AIR SPARGE/OZONE []PUSH POINT(GP or CPT)GROUT SEAL PUMPED: []Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> []SOIL BORING []HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: []OTHER APPROX.BORING DEPTH []BOLTED TRAFFIC BOX or []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 /> n <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. F <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Companyprq�'ec-t C,eolog i S t- <br /> Print Name zr► Oi\ t'ej Date 5 f D4 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: ` /� /1 <br /> Application Accepted ByW6 Date Issued l 2 1 Area <br /> Grout Inspection By Date / 115 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> S R# 0&1 �7{ <br /> C-57_ WC=WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/30/02 <br />