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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 County Environmental Health Department. <br />y� r"Il�(S �-, _ .� .. ;Assessors <br />WELL Location r "�-� Cross Street ty ZipParcel# <br />Owner �`' S"""' "" Address / 2� '" t & � / �7 a <br />yy�� i//���ty�Zip�hone# /�1/7� p f)/ Q <br />C-57 Contract r�Q 1� f G dress S�3z ( itv ' _Zi ic# L75&one# % [ � o �/( 0 <br />Consultant /Sub Cntr A 67(C -Z Address 85-? 5A4_ -N:5 ?(9Ity _'K'kxzV&ic# Phone# , ,n5 44(,71�e� <br />GIS Coordinates: <br />WORK TO BE PERFORMED: <br />p NEW WELL / BORING <br />G SOIL BORING # _ <br />p WELL # <br />a 'Other <br />COMMENTS: <br />Township, <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />Range Section <br />STRUCTION (choose a below) <br />OVER -BORE. DIAMETER C/ <br />a PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICAT ONS <br />,MONITORING HOLLOW STEM DIA. OF BOREHOLE �I LTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS/ TYPE OF CASING: O STEEL U PVC 0 OTHER: <br />0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL �REMIE TYPE TO BE USED: VUGERS 0 HOSE <br />a AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE:,MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING U HAND AUGER GROUT SPECIFICATIONS <br />a OTHER: a OTHER APPROX. BORING DEPTH iia . " 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />% / COND CTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: IN e �1 1��� t_L f C �- <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 Ordwi a ces, Rules and Regulations, and all applicable California State Laws. <br />�// — �c�%� <br />Signed x G" ti� Title/Company � C !� <br />Print Name Wt t ! ��G -11 `% Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 17�� kiLl/ <br />WORK PLAN DATED: _ 01 dlY . 0 Ly <br />Application Accepted By Date Issued C G A ea <br />Grout Inspection By Date ` /inal Inspection By I a t o <br />Destruction Inspection By 4 Date . j <br />COMMENTS / CONDITIONS:a _t�` l - 7 ' o i <br />.1111 L2 LI <br />t� <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PER RVICE R EST # <br />INVOICE <br />C-57_ WC_ -WAIVER_ C-57 Letter of Authorka't t <br />n/l <br />o sign permit_ Encro ¢at.dee—"' 9/30/02 <br />