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r^� FIFTH FLOOR h'AUt UZ <br /> X002 08: 18 20946 33 <br /> WELL PERMIT APPLICATION FORM , ^ i /.,& D <br /> ZT bl/ <br /> SAN JOAQUIN COUNTY VITIV3ENVIRONMENTAL HEALTH DEPARTMENT (EHD) 2002. <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 ENVIRONMENT HEALTH <br /> (209) 468.3449 PERMIT/SERVICES <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 TMe,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Departmen Assessor's <br /> WELL Location �f,, b '�� Cross Street City zip 7 20 Parcel# / j6\I-OSO-i7L( <br /> ��� Cry�1`r � Address - '�'-� 4 V11:22 I ,�a� City ,moi•< ;x� Zipa':YJI, Phone# <br /> PROPERTY,Owner 1— <br /> C-57 Contractor fLt~3d= �=:v'=%9N'sE <br /> Addre CitykA,: �r Zip4=f-1 uc#'t<<-''Phone# �i ti-li✓r'17 <br /> Consultant/Sub Contractor Ues -c ' Address IZ S T xyc <br /> GIS Coordinates:X .Y ,Township Range Section <br /> WOR!SZO BE PERFORM <br /> W WELL/BORING,-CQEj,4EOPROBE,HYDP.OPUNCH,HAND-AUGER.OTHER`) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# g OVER=BORE <br /> n Ip!_LL# Q PRESSURE GROUT <br /> 'Other. Grout Specifications: <br /> COMMENTS: c=P-N -1p ► � -' 11 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITOPING (1 HOLLOW STEM DIA.OF BOREHOLE 1.5 ' MULTIPLE CASINGS?DYES gNO WELL CASING DIA: 1Z <br /> fI EXTRACTION n.AR HAMMER/DRIVEN CASING THICKNESS Wn TYPE OF CASING: G STEEL O PVC Il OTHER: <br /> M VAPOR r]MUD ROTAPY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: C AUGERS `j}'I-IOSE <br /> fl AIR SPARGE n PUSH POINT GROUT SEAL PUMPED: Ye jkNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> II SOIL BORING n HAND AUGER GROUT SPECIFICATIONS: P5C� 1`�ie�Ct�+r`Cs✓�' <br /> it OTHER: 0 OTHER APPROX.BORING DEPTH 1 OO j BOLTED TRAFFIC BOX or U STOVE PIPE <br /> _ CONDUCTOR CASING PROPOSED? N-0 (if YES,list specifications here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CAI-t-THF I INIT IV INSPFCTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina o tales ar,d Regulations,and all applicable California State Laws. <br /> Signed x wJ n�� Title/Company <br /> Print Name �t� �P�►�5cry Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED.- <br /> Application <br /> ATED:Application Accepted By Date Issued ///I,//,o —Are U <br /> Grout Inspecticn By Date �Z Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> EACCOUN-nNG ONLY: AID# Fora <br /> FEE INFO AMOUNT REMfTTED CHECK# REC'D BY DATE PERMIT l SERVICE REQUEST# INVOICE <br /> ci-% �� srx 00515L)2 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br />