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WELL PERMIT APPLICATION FORM SITE <br /> r:fd;'(( C`Ih'Et�iAi. FfE'MNWOAQUIN COUNTY MITIGATION <br /> f4V RdA'Mt_NTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 03 Jl o4 y . #Mp I,j1ird Floor, Stockton, CA., 95202 <br /> an " (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 /> Assessors <br /> wL43 3 <br /> L Location r�� Cross Street City l Zi Parcelr#� <br /> PRIERTYOwne�J ��t[c y �OA3bddress l�(7� CG>ar�� _Zip960 Phone# <br /> ,tSGrQK 'x11tL 14 '.P 7. !�• EA3�� Sf '- WCDdlUrd 5�7�v (�2 f 5 i) lyjp ZLfZ`� <br /> C-57 Contra o Address City Zi Lic Phone <br /> Ca C%+k�'x �tSu��ar 2— 0 i I,tJG( , 0-F 1 l t) lP(�3- <br /> onsultant Sub Cntr Address City bbd tYd Lic#I)A Phone <br /> GIS Coordinates:X Y Township 35 Range Section' <br /> WORK TO BE PERFO • <br /> []NEW WELL/ ORING (CPT,GEOPROBE,HYDE--'INCH,HAND-AUGER,OTHER-) DESTRUCTION (choose type below) <br /> OIL BO S+�'1 <br /> IR <br /> BORE. DIAMETERWELL# n SURE GROUTOther , jGt-t 1�� ��� IFICATIONSCOMMENTS: m Z Z <br /> ir <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING []HOLLOW STEM DIA.OF BOREHOLE r ([]MULTIPLE CASINGS []MULTI-LEVEL W ELL CASING DIA: <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS QTY,tP�O ICCASING: []STEEL []PVC []OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAPUI lti t`�"' TRI MIE TYPE TO BE USED: []AUGERS []HOSE <br /> []AIR SPARGE/OZONE []PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ',SOIL BORING []HAND AUGER GROUT SPECIFICATIONS <br /> '[] <br /> OTHER: OTHER ��D%l!L APPROX.BORING DEPTH ('off)- !qQ []BOLTED TRAFFIC BOX or (]STOVEPIPE <br /> �(L11� 3 YJC}'c PISS.L,'e��`I dl�lvl�CONDUCTOR CASI�NIG PROPOSED N + (if YES,list specifications in comment section) <br /> COMMENTS: 1L,7w �.11C, R�1 Qrtlllr �, �� lU 1 l_+���P('� �v�,ui�cl,��.{Yh ` Cty►t,�eG ' <br /> TS. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMI <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 Ordi ances, R . es and Regulations, and all applicable California State Laws. '/ L <br /> Signed x `�� ?/L &_," 1 Title/Company ton jcct IST <br /> Print N e \ 177 r �5�� ��(� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: �✓1_�f DW Ct4 4)p <br /> Application Accepted By i k'W� Date Issued b� Areal <br /> Grout Inspection By Date Z Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# <br /> C-57 W(---WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/30/02 <br />