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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT 1V <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' ►,` <br /> WELL Location ���5 S Sf t(6 {VQIiA(l WCross Street Assessors <br /> LSC. _City JPO T011 Zipg5ZO5 Parcel# <br /> Owner PROPERTY -� f W } 5f City <br /> CL� p q <br /> Owner i_1Y1f�N.l^i1G;l.TQOlrrTlniL —Address.1 I�S,�1 P l fet lV t1/rC�,L�1+E1J',Ci �1i Zip -t 5 Z(�JPhone# f`t)-q 337 <br /> C-57 ContractorNfk�i:YlfA1 l VitGlt4ress)) q 31 S fur 0 City Z �� Zip ` 5 Lic#�hone# J y�7—l�d b <br /> Consultant/Sub Cntr�ANA ( p0GVijM_tEulRtidress� ;l 5lucw Pj City I r Lic# Z? 4 <br /> Phone# 7-100(..+ <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,"EW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) D DESTRUCTION (choose type below) <br /> X-SOIL BORING# D OVER-BORE. DIAMETER <br /> D WELL# D PRESSURE GROUT <br /> D'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLEIV5" D MULTIPLE CASINGS D MULTI-LEVEL WELL CAS%i <br /> D <br /> EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS—�N Y'1 TYPE OF CASING: D STEEL D PVC D ``OTYP�iR��vv: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEATREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE/OZONEAIP'USH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes ArNoL1(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING D HAND AUGER GROUT SPECIFICATIONS �t?fT laVtd 1,6m <br /> a OTHER:_O OTHER APPROX.BORING DEPTH LAS _D <br /> BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED �� (if YES,list specifications in comment section) <br /> COMMENTS: -F <br /> NOTE: OFFSITE BORINGS REQUIRE A66ESS AGREEMENT OR ENCRO C MENT 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 and Regulations,and all applicable California State Laws. <br /> Signed x vV ,( Title/Companyb10I i / lTl1�GDtL�� " ,=rr' �t�Z1+t4 <br /> Print Name ��� Date gyP 5, 4 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, DDESS: St-v n—A)z w.-d c,, <br /> WORK PLAN DATED: dT <br /> ? 04 <br /> Application Accepted BDate Issued Area Zt <br /> Grout Inspection Bate 4 8' O Final Inspection By bU Date <br /> Destruction Inspection By Dat <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC* <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3SoI x`t.0° 1`lq�i( ( Z I`( o�( SR# 3 C �t 3 <br /> C-57_ WCWAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br /> _ <br /> FILE Copy <br />