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�A�,E`vEG WELL PERMIT APPLICATION FORM SITE <br />E SAN JOAQUIN COUNTY <br />2pp4 MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />MAR Gout 10 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br />,W jo RONME T (209) 468-3449 <br />H�TN HEPAR <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 9-1 i 15.3 and the Standards of San Joaquin County Environmental Health Department. <br />l Assessors �0/.�� <br />WELL Location (POD S, /,, - � /641 fU Cross Street J S� City ('041r^a� Zip%S>' 30 Parcel# 1910 X9 <br />PROPERTY ik&atVl1,/_I // <br />Owneri�(WLL'Ad t,f- T Address %<6 06 S- �^ 1a'^ AjCity"1W Zio95-nahone#1 y%!!ll (,J `8Z—Q3 7-0 <br />C-57 Contractor V C Y 6 aA Address475? tom° le,4 Cit) 4A1(-1 f -L Zi�Lic#y�/6 Phone# l`�2 SJ 3n- <br />30 <br />Consultant/ Sub Cntr Address CityLic#��� Phone S3�-/ b " ism <br />GIS Coordinates: X Y_-_ Township s Range 6� Section 7— <br />WORK <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />0 SOIL BORING M # 0 OVER -BORE. DIAMETER <br />'WELL # W 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPES OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Ir <br />X//`MONITORING XHOLLOW STEM DIA. OF BOREHOLE n [] MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA# <br />[j``EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5CLk-40 TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: XAUGERS [] HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes�No NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />[] <br />OTHER:_0 OTHER APPROX. BORING DEPTH /5r S 'BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (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 />All <br />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Or lances, Rules "d RReegulationss, and all applicable California [�%State Laws. <br />Signed x "4% 1 1.10411 lle � 6r Title/Company I a� �C.� j l� �71 �S CJ✓1 (/ li%tn� <br />Print Name skell2h Ii C" 'w 96 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS:15<0 <br />WORK PLAN DATED: 1-1-13143 <br />Application Accepted By C Date Issued_ <br />Grout Inspection By Date Q Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />01FM <br />t <br />ACCOUNTING ONLY: AID# <br />FAC# 5R © a $ z <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / INVOICE <br />3501 <br />'2Cl <br />$--35 <br />1oo ( <br />S 6qSR# <br />C-57.__-_ WC --WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/30/02 <br />