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WELL PERMIT APPLICATION FORM <br /> 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 De vlopplent jjt�_,Qhapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location_S Jf,tJ �C aF't`> M d„Q tl �. Rokt,Rd- Assessors <br /> t4ross Street N 1 <br /> _.31�t _City I.C. <br /> �— — ' _ZiP q5�'�r� Parcel#__�_ <br /> PROPERTY Owner�CrtnS�)_.on'%tA .�Address7560h <br /> r"rnui RdCity —Zipg53'76Phone# bgrg3el- %&5 <br /> C-57 Contractor(zyenn�r;tt;iypCY(-T11 % <br /> r {, `' --^----- <br /> ddress��O t�n,r !?,L City A' ZZipg 4S$ Lic# _ <br /> _,3. y.$,. _ Phone#q5SgO <br /> Consultant/Sub Contractor {� _Addres521ll ��.k„�, (hkI-Dr Ci c_ 1_ <br /> �i do 3-p h''' ° Li- Phone#916'(74-J-bC6 <br /> GIS Coordinates:X ,Y ,Township Range 9 Section <br /> WORK TO BE PERFORMED, <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') �� /� <br /> D SOIL BORING# &DESTRUCTION(choose type below) <br /> 0 WELL# 0 OVER-BORE <br /> 'Other: Q SPS'11RE GROUT <br /> COMMENTS: ,�Q, I„ Grout Specifications: ncicQ416ce Po�4_10nd <br /> 0. C h Lol. mom� I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Q <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL <br /> 0 VAPOR 0 MUD ROTARY D PVC p OTHER: <br /> DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS <br /> p AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: D HOSE <br /> ❑Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') lzi <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH <br /> 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 'COMMENTS: CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT WINS CTOR 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 Ordtna ces, Ruts a d Regulations,and all applicable California State Laws. <br /> Signed x1120 AO:L_ Title/Company 6Wr6 -,44,4�jq6)5e comp <br /> Print Name QI(,timet gb V �yl<0 �/ — �p Z— <br /> DEPARTMENT USE ONLY Date <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED:: av - , <br /> Application Accepted By be1'` <br /> Date Issued_L_3 f0? AreaC a t%t <br /> Grout Inspection By Date /.Z- 03 Final Inspection By <br /> Destruction Inspection By Date <br /> Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> cera <br /> PIE FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �qoz 60_ 66 (�1X3(0 SR# Do 32-014 <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc 1/25/02 <br />