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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />OCT 12 2004 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />ENVIR0i�d1'%IENT Hi=,-;L1ly (209) 468-3449 <br />)rr'i - <br />SITE <br />MITIGATION <br />UNIT IV <br />�ERV r" <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 />Op I� Assessors <br />WELL Location �`J C. &vHyJ Ut,, 9,1 Cross Street City l r_C./ Zip ti53-46 Parcel# 21 35004 <br />f <br />PROPERTY (� 1I <br />Owner 8c�.�? ye Address z����F U,Lti�q 5�, City t iv, ) Zip`lgS��Phone# <br />C•57 Contractor �TYBgq L�,i 11� j ITe41 ,,j Address 9SU 04AoW kA City cdy ,,C z Zi.05D Lic# $i 5 Phone# �ZS- 313- Sip <br />Consultant/ Sub Cntr ATC Asoc"Af,f, Address P,)) Ar q,'9Cityhj A Lic# Phone# Z(1 -S39 -222 j <br />GIS Coordinates: X Y Township T25 S Range R 5 E Section 16 <br />C� <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING CPT EOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # CPT i CPT Z OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: 4- <br />S - <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE Z " 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL �3' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE VUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED NV (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 I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinance , Rules and Regulations, and all applicable California State Laws. <br />Signedx. L� � � � AA Title/Company -_-' " r py'A-5 <br />Print Name ��� rt-�� Date t� (ti( 0-1 <br />SITE MAP IN UNIT IV <br />WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />Application AcceptedL G Date Issued 10-13-o4 Area 45-q <br />Grout Inspection By B Date Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: Ad yg ri e em P of CPT-( and CPT -2- <br />4, <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE RERMII I SERVICE RE T# <br />INVOICE <br />3501 99.00 <br />9-9,00 <br />sR# 003 1 q85 <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ chment doc 9/30/02 <br />