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FILE COPY <br /> 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 /> 2005 JUN 37 AM 9: 511 (209) 468-3449 <br /> NT -REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application h fo"RAPA <br /> nCounty for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin Cor>iOof 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location 3oZq E . LN Cross Street o1•MA•J Ro Ci Assessors <br /> CI'rY OF SToCKYO ty �STOCKTD/, Zp Parcel# Zy-300-09 <br /> PROPERTY Owner <br /> //hCCUNfC-tPA1- ,O[,Tl,47-gs�nAddress ZSDD NAVY PR. CitySTOCKTotlZipg5Zo6 Phone# Z01-937- 8790 <br /> C-57 Contractor- yJ 6 5 �� wv A� e4,n! � ; City Zip Lic# Phone# <br /> U•S.G•S• S7,3S KERRNy vic�l9,�D. <br /> Consultant/Sub Cntr f'ED• GoV Address S0 rrE u D• City SRN DrEC,OVc# Phone# 658 637 4005 <br /> GIS Coordinates:X Y Township 21J Range (>E Section 11 -1- <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> SOIL BORING# [)OVER-BORE. DIAMETER <br /> -;H�NELL# 0 PRESSURE GROUT <br /> ;•'Other GROUT SPECIFICATIONS <br /> COMMENTS: /iv -" o�' .�-L �D ors i f euf <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING [j HOLLOW STEM DIA.OF BOREHOLE j]MULTIPLE CASINGS I7 MULTI-LEVEL WELL CASING DIA: Z <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> 0 VAPOR MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> []AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> []SOIL BORING [j HAND AUGER GROUT SPECIFICATIONS <br /> P.OTHER: BOTHER DDE K APPROX.BORING DEPTH '" I ado <br /> - [I BOLTED TRAFFIC BOX or H STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: UIJ.SATUlZATEP-i?ON <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 <br /> �and <br /> o Regulations, and all applicable California State Laws. <br /> Signed xc `y�i�,.�c0 G� L/i�A�� Title/CompanlO /GART <br /> Tint Name eNNiS A� Date 6 O <br /> DEPARTMENT USE ONLY <br /> a r Gni �i <br /> 31TE MAP IN UNIT IV FILE, ADDRESS: 5 <br /> CORK PLAN DATED: <br /> &4 <br /> application Accepted By ( Date Issued -OS Area <br /> 'rout Inspection By <br /> -Date-Final Inspection By <br /> testruction Inspection By Date <br /> :OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 13 - S R# 00 <br /> '-57 '//WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc 9/30/02 <br /> c= � Z— <br />