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L <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 /> L <br /> (209) 488-3449 <br /> MWEIFUNDABLE PERMIT EXPIRES I YEAR FROM DATE MSSLIED <br /> Application Is hereby made to San Joaquin County for a permit to oorrsbuct and/or install the work described. This a <br /> Joaquin County Development Titre,Chapter 9-1115.3 and the Standards of San Joaquin pP�1bn is made in compliance with San <br /> q County Environmental Health Department. <br /> LAssessors <br /> WELL Location Cress Street <br /> c1tY Zip Parcel# <br /> PROPERTY <br /> Owner Address City Zlp Phone# <br /> C-57 Contractor Address Crit' Zip Lic# Phone# <br /> L Consultant/S0b Crm Address 0tr Uc# Phone# <br /> GIS Coordikudes:X Y_ .._ Township Range Section <br /> WORK Tow <br /> PERFORMED: <br /> L Q NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER") a DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> II WELL# 0 PRESSURE GROUT <br /> 0' w GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL IINSTAILLATI CONSTRUCTION SPECIFICATIONS <br /> ` 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> L 0 EXTRACTION 0 AIR HAMMER/DRIVEN 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 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list speditatlons in comment section) <br /> COIrMAENTS' <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> # 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> L I hereby cerft 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/Company <br /> Prht Name Date <br /> y DEPARTMENT USE ONLY <br /> L SITE MAP IN UNIT N FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> LApplikedon Accepted By Data issued Am <br /> Grout Inspection By Date Rnal 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/SEFMCE REQUEST# INVOICE <br /> SR# <br /> C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit,„Encroachment doc_ 9/34/02 <br /> I <br />