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EMW EMM <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGAT101V <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) ( , ,�I . <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 /> (,I Assessors <br /> WELL Loccation 'fob QeW-totit Cross Street City VA Zipql�/05Parcel# <br /> Owner :tf.CfL fuC� L wEOS Address 70 BA 230 City_ ZipPhone# c <br /> C-57 Contractor + fe Tat-Address flSC I►Gi'J;cF t� City i"�( 0 ip�!Lic#� Phone# t `� 4b <br /> Consultant/Sub Cntr , . Address 8�1 J1" City Lic# k7 Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> fSOIL BORING# 'Z 0 OVER-BORE. DIAMETER <br /> D ELL# 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALfi� TREMIE TYPE TO BE USED: 0 AUGERS )-IOSE <br /> 0 AIR SPARGE/OZONE XPUSH POINT(GP o CP i GROUT SEAL PUMPED: �es 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 'Pcf}1C'* <br /> 0 OTHER:_9 OTHER APPROX.BORING DEPTH I00` 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PRCPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE 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 a--n--fid Regulations, and all applicable California State Laws. l J r <br /> Signed x�a tl"t -a' ';L Title/Company Ya, 6ypim <br /> Print Name V Gl l rcm_ L, SL1 � Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3400 Jljew-6 r.' 'ZI y.&A <br /> WORK PLAN DATED: tj 4n 11 u .21 2 ol)4 <br /> i all <br /> Application Accepted By y,e_+or;AM da r+ aur Date Issued Ma regi1�Z-7. Zo o 4 —Area—)45'q <br /> Grout Inspection By ViLtby:& ht g,ed Date 7 6 Final Inspection By I/,cki &6&t-jLA4S Date T"7"d y <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: A d V ot ri Ori <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3501 b o SR# 0037 3/ <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />