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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY <br /> COv ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> O (209) 468-3449 N 13 2003 <br /> Application is hereby made to San Joaquin CouOntyor-REFUNDABLE SUED <br /> permt consruct a d//orr iiIT E ostal the work desunn cr bed.lThis application is rNrqq�V�Q(R�jg�CompLRVI 6vilS n <br /> Joaquin County Development Title,Chapter 9-1111�5.3nd the Standards of San Joaquin County Environmental Health Assessors <br /> L�VICES <br /> 3 13 I M �7K Cross Street_City ae'L�ip � w� Parcel# <br /> WELL Location -k{7` Zi' 4S2?? Phone <br /> PROPERTY Owner 110 A ILeS Address �W`' �3c3 City S7 P <br /> a`� Y l i l r Address Ie7J oxy I� Cjty' I Zip iSCw l Lic#?Z`�+o�' Phonel -7 7�-Vr" <br /> C-57 Contractor a <br /> aq� yOVZ city oL(�-uc# 347 Phone# 77z-36k% <br /> Consultant l Sub Cntr r� Address <br /> Township Range Section <br /> GIS Coordinates:X 'Y ' <br /> WORK TO BE PERFORMED: DESTRUCTION (choose type below) <br /> p NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') IkVER-BORE. DIAMETER <br /> 0 SOIL BORING# p`PRESSURE GROUT <br /> DWELL# GROUT SPECIFICATIONS <br /> p*Other <br /> COMMENTS: <br /> TYPE <br /> E OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS .2 <br /> ,pw1ONITORING a HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS h H Q TYPE OF CASING: 0 STEEL -%PVC B OTHER: <br /> a VAPOR D MUD ROTARY DEPTH OF GROUT SEAL -?y TREMIE TYPE TO BE USED: AUGERS OSE <br /> p AIR SPARGE/OZONE O PUSH POINT(GP or CPT)GROUT SEAL PUMPED:-&Yes p No (NOTE: MAXIMUM FREE-FALL DEPT IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> u OTHER: a OTHER APPROX.BORING DEPTH /_ 0 <br /> BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED <br /> if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS HOURS S REQ C ES REQUIRED FOR INS AGREEMENT SPE ENCROACHMENT PERMITS. <br /> S <br /> I hereby certithat I have Prepared this application and that the work will be done in accordance with San <br /> County Ordin nc Rules and Regulations, and all applicable California State Laws. C <br /> Title/Company <br /> Signed x <br /> c <br /> —a I+-C(fv�J J Date O <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, DD ESS: <br /> WORK PLAN DATED: i I ICA 03 <br /> �z /5� Date Issued ���� Area <br /> Application Accepted Byer— Date <br /> Grout Inspection By <br /> Date Final Inspection By <br /> Date <br /> Destruction Inspection By <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE�CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# IN <br /> 3 52 0 60 $ 60 ILH & SR# 003245y <br /> 9/30/02 <br /> C-57_ WCWAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> _ <br />