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ED WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN-COUNTY MITIGATION <br /> �� ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT A <br /> PIAN O 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRC)AENT HEALTH. (209) 468-3449 <br /> PERIPT/SERVICES 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 /> 3.7 A/ f Assessors <br /> WELL Location -"� O ! '' JrQ y ��V�" Gross Street 1 0 V- r City -r,( 4 C_. Zip Q 37�° Parcel# <br /> PROPRTYownerE\�a« 5� ffrK� Address �,'1�D"J`I `7l Cy YaCW Zip�S3x�Phone# y <br /> C 57 Contractor �tiYBVI�i Address o� {(01 44ct't5 r� City$4LO��dZip°14S 1?Lic#70 I- Phone#S19` <br /> Consultant/Sub Cntr Cg's ASSOc1�LiS Address City Lic# Phone# <br /> GIS Coordinates:X _,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL I BORING (CPT G PROB HYDROPUNCH,HAND-AUGER;ATHER*) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 3 p OVER-BORE. DIAMETER <br /> O WELL# 0 PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> "COMMENTS: <br />_ TYPE OF WELL INSTALLATION TYPE'_ ti" 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 SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE &IPUSH POINT GP or CPT)GROUT SEAL PUMPED: 0 Yes V:�o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: OTHER APPROX.BORING DEPTH_ S SIS 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 Ord'n ices, Rules and Regulations, and all applicable California State Laws. I <br /> Signed x rt TitlelCompany �✓IU._,:�eC Q rl s4 <br /> Print Name r mnq t y'� __ Date <br /> DEPARTMENT-USE ONLY <br /> SITE MAP IN UNITIV FILE,ADD ES 3;k 4-o a J <br /> WORK PLAN DATED: <br /> Application Accepted By. Date Issued f" Area <br /> Grout Inspection By ate Final Inspection By Date 0 <br /> - r <br /> Destruction inspection By Date <br /> COMMENTS 1 CONDITIONS: ` <br /> ACCOUNTING ONLY:, AID# FAC# <br /> z <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY `DATE PERMIT/SERVICE REQUEST# INVOICE <br /> a I4 b d2 S R# . los s <br /> C-57_ WC--WAIVERC-57 Letter of Authorization to sign"permit Encroachment doc 9/30/02 <br />