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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 /> (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 ounty Environmental Health Department.Assessors. <br /> 6140E STaCu `BILA Cross Street'City S�oG�Tbti zp �SZrrXo Parcel# /5 %-l7-D7 <br /> WELL Location � 1 � ���/ <br /> PROPERTY ICJro 5 �1('GL) ��✓L, Clty_ �_Z�p 1 _Phane# Z: �� <br /> Owner �t6 yj.W o�Gi Address 1 - <br /> C-57 Contractor "' I(�Ltl t 1`I LV I Address (0/O($ M'(a.yz-� �.� City W�+D[EyOfYdip `15670 Lic#�1rd0-r-Phone# �b d - f <br /> ba•ea'rrD (r_9 e s V x`` ck1eL Lic# b4D 7 7 Phone# b1-IOdG <br /> Consultant/Sub Cntr EU 91kw`+llAgd SµrtCily�}D_L <br /> Y ,Township Range Sectioh <br /> GIS Coordinates:X - <br /> WORK TO BE PERFORMED: - DESTRUCTION (choose type below) <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) a OVER-BORE. DIAMETER <br /> 0 SOIL BORING# - 0 PRESSURE GROUT <br /> g'WELL# 3 GROUT SPECIFICATIONS <br /> a*Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING -IOLLOW STEM DIA.OF BOREHOLEy_;_ a MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: Z <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 51�e 46 TYPE OF CASING: a STEEL XFPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL � TREMIE TYPE TO BE USED: AUGERS HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP orCPT)GROUT SEAL PUMPED: 0 Yes XNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ro('H .A 1 <br /> OL <br /> TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: - 0 OTHER APPROX.BORING DEPTH yJ� � - i <br /> CONDUCTOR CASING PROPOSED ND (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 cartify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> Ccunty Ordinances, Rules and Regulations, and all applicable California State Laws(. n E <br /> Signed <br /> �jA,yl•g�� ri1 Title/Company C Cl T7 _ <br /> --a-�' .,, <br /> Print Name l 1 Q <br /> jtp { Date 3 Z3 O <br /> DEPARTMENT USE ONLY _ <br /> SITE MAP IN UNIT IV FILE,ADDRESS: - <br /> WORK PLAN DATED: <br /> Application Accepted By ued�1 Ca��C-YI `' 1t�`T Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By D e <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# - FAC# - <br /> PE7CODES FEE INFO AMOOUNT REMIITTED CHECK# R 'DB DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# 3 <br /> C-57_ WC -WAIVER— C-57 Letter of Auth za ' o sign periti Encroachment doc_ 9/30/02 <br />