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WELL. PERMIT APPLICATION FORM <br /> EG�wE " SAN JOAQUIN COUNTY. SITE <br /> 5 Z�Q ENVIRONMENTAL. HEALTH DEPARTMENT (EHD)' MITIGATION <br /> cpU 304 E. Weber, Third. Floor, Stockton, CA., 95202 UNIT IVB <br /> JOAQ ,M�N�AENT (209) 468-3449 . <br /> 5P-r�0�1`1 iPA` NON-REFbNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application isui � ade to San Joaquin County for a permit to construct andlor install the work described. This application is made in compliance with San <br /> Joaquin County Deiivelopmlent Titl�e,T-Chapter 9-1115.3 and the Standards of San Joaquin ounty Environmental Health Department. <br /> WELL Location 1154 S racu BIA ' Gross Street r n Assessors <br /> City Q1u zip Parcel# l I -D7 <br /> PROPERTY, <br /> Owner A Address} _ <br /> �S 5 I raG d City s` J!I._Zlp phone# Zy7 z <br /> C-57 Contractor Sli to t"� Address':Io6t$ �`(;[0.ZzD L/lSQ City udiea,4r,1, Lic# Phone# tb� I <br /> i <br /> Consultant!Sub Cntrq pfl' ' ,/ i <br /> -ANANWOress_8 .7� S City �Lic# �Ci Phone#_ "76 -�0�`s_ <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPR03E,HYDROPUNCH;'HAND-AUGER,OTHER*) a DESTRUCTION (choose type below) <br /> ra SOIL BORING# Q OVER-BORE.' DIAMETER <br /> P '"ELL#— - 0 PRESSURE GROUT <br /> 0`Other <br /> COMMENTS; GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ` <br /> /MONITORING OLLQW STEM DIA.OF BOREHOLE0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA.'2—n <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS.MO TYPE OF CASING: 0 STEELpVC 0 OTHER; <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ` CJ TREMIE TYPE TO BE USED: YAUGERS 0 HOSE <br /> {]AIR SPARGE/OZONE 0 PUSH POINT(GP orCPT)GROUT SEAL PUMPED: 0 Yes eNb (NOTE. MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HANDAUGER GROUT SPECIFICATIONS aVA AAT <br /> 0 OTHER: 0 OTHER '.-APPROX.BORING.DEPTH ��J OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED ALP (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 Lhave 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 /> k <br /> Signed x Title/Company [ /� <br /> Li <br /> Print Name Date ✓ �3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ; <br /> WORK PLAN.DATED: ZI 4 <br /> / )/ ► <br /> Application Accepted By ued l�� v r F Area, <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R 'D B DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> ,Vt) : Z� 13 L SR# <br /> 3 <br /> C-57 WC_-WAIVER C-57 Letter of Auth za ' o sin ermit—Encroachment doc_ 9/30/02 <br /> a- <br />