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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 OKIbINAL <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 />1, Assessors <br />WELL Location 7.w� b'V . rlal rlil'l�r Cross Street �IC`17 CityZip 2CC1 Parcel# Off?°U <br />PROPERTY Owner CC-.Y)a1')09j I I Address City<S((,CIZ.IQJ(42 ip C1,50 Phone# <br />C-57 Contractor WDC- Addressq;K& Cxz <br />cON�ZGuyi 1--.q ityZip_ Lic#zy73zPhoned,��--c—) (o(,2-- Lc{ <br />Consultant/ Sub CntrSL ln4(-=f,--PCAadress -�_j7 KtIC�rrC Ili, Phone#C11 Klc1-0440 ) <br />GIS Coordinates: X Iu'IA Y Township r j Range N .1 (4 Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />WELL # M W - 11 MMi— I Z 0 PRESSURE GROUT <br />0.Other GROUT SPECIFICATIONS <br />COMMENTS: 3C)' )' b« S <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING gHOLLOW STEM DIA. OF BOREHOLE %" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS YrleL , 9L TYPE OF CASING: 0 STEEL , 'PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL s? r TREMIE TYPE TO BE USED: JKAUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: $Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS (1PO + CPfYC-n-k- <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH '�3 D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED Iii / A (if YES, list specifications in comment section) <br />COMMENTS ' Cl r' ' 7 `r'1 S ' <br />W <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR EN ROACHMENT 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 <br />Print N <br />Title/C <br />DEPARTMENT USE ONLY <br />t <br />SITE MAP IN UNIT IV FILE, ADDRESS: 3 Z 0 2 W, -_s: - 14,n m me r La n e, <br />WORK PLAN DATED: 5d, t2+d1 a1 key 19 2() 0 3 <br />Application Accepted By �� �- Date Issued_ o dey, boy, 18. 2004 Area l 45- q <br />Grout Inspection By Date 11 6 Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: T. n S l 4'�`t 1in of 1'a'1 o7l do Y i rt 14. Wia-1_1 5 MW -11 ai arl A4 M-/ - i 2 <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATEPERMIT I SERVICE REQU <br />INVOICE <br />X501 <br />84.a <br />if 89-0,0 <br />R# 00404 0 (a <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroac men oc_ 9/30/02 <br />