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WELL. PERMIT APPLICATION F..oRM 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 Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location S/1n L .i �J �� V Cross Street M ci �� Y City "°��'�` Zip ���/C' Parcel# <br /> PROPERTY <br /> Owner J'�e /`I l' /-t Z Address YIC' L�'K+J r /{i1r City �G/�:c� Zip%T3J� Phone# vim/ y<�� <br /> C-57 Contractor Address City Zip Lic# Phone# <br /> 1Q67L' Jre /ac' A'?-7-hC `f'/E ` S,/ 5°.1'JJ <br /> Consultant/Sub Cntr/r! / e cll f M 1 Address wt;W}e/t 4(/r ��>! CityCur./-;-1'Y Lic# Phone# <br /> GIS Coordinates:X Y ,Township A& Range Section <br /> WORK TO BE PERFORMED: <br /> XNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-A6ERTHER•) ,6 DESTRUCTION (choose type below) <br /> SOIL BORING# �Yw� �`I't� a $OVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT <br /> a'Other .' GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE'�$MULTIPLE CASINGS AMULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC OTHER: Al U''f <br /> $VAPOR a MUD ROTARY DEPTH OF GROUT SEAL O (1 " TREMIE TYPE TO BE USED: Q AUGERS a HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes ANo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORINGHAND AUGER GROUT SPECIFICATIONS *j^"e —I ''k <br /> a OTHER: 0 OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED IV C' (if YES,list specifications in comment section) <br /> COMMENTS: Q <br /> NOTE: OFFSITE BORINGS R QUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x /-K� Title/Company SC' e '1 <br /> Print Name / C / C Date /0 7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: H 10 L-C)Wc1y G(AA OL <br /> WORK PLAN DATED: (a o <br /> Application Accepted By h Date Issued �-I b Area <br /> Grout Inspection By_� ��wnt,✓� Date ld 50 O Final Inspection By D O Date 1 <br /> 11 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING#INFO <br /> # FAC# <br /> PE CODES OUNTREMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ��p ( $� _oo a3�-� (,�•� 10 u o SR# <br /> C-57 W(_-WAIVER— C-57 Letter of Authorization to sign permit Encroachment doc 9/30/02 <br />