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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 Joaquin County En .Smental�iealth Department. <br /> Assessor's <br /> WELL Location /� .7��J-a l (�Cross Street 11, Q� City t D1�S9V/ �l Zip Parcel# /83 -Db-00� <br /> PROPERTY Owner h� Nom,(�N/ Addresssl /3S=i-I L/�. /�y(Dy _ O(�1C/iitty Zip /Phone# <br /> C-57 Contractor/ (/�CfJ �j/� Address 133/ �$�2Gttu /CEf City J/K�_ Zip_2ic# Phone# 2 <br /> Consultant/Sub Cntr �So�we Address City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL/BORING(CPT GEOPROBE,HYD��PUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> $OIL BORING# � OVER-BORE <br /> 0 WELL# PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE ;I," MULTIPLE CASINGS?a MULTI-LEVEL?0 WELL CASING DIA::/V-4- <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: N�1 <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 20" TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/Ozone PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: AXIMUM FREE-FALL DEPTH IS 30') <br /> ,SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: A2'-jZ�c 74- <br /> []OTHER: 0 OTHER APPROX.BORING DEPTH w20 "' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? A,411L-7 (if YES,list specifications here): <br /> *COMMENTS: SGlC_ Z/ A�& al— /st' o <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 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 Or ' nces Ru nd Re lations, and all applicable California State Laws. <br /> Signed x /J,/ Title/Company <br /> Print Name , " Date 1033) d Z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> Date Issued /� �Z- Area <br /> Grout Inspection By Date / D Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: o. <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02 <br />