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ORIGINAL <br />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 />0 <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 />WELL Location <br />` <br />4'ZS S- <br />r y <br />L. r' p02,c�C <br />Cross Street Ntkf�l' City <br />Fflk� �6-, ,Zip <br />Assessors <br />Parcel# <br />PROPERTY Owner <br />J wv+u <br />Frsk— <br />Address <br />City Zip <br />Phone# L - L <br />3D <br />C-57 Contractor t v Address % u 1 City L -S Ix � Zip riD' C 1 � Lic# y� L Phone# ,'16 -" 7 77 - y/ Cy <br />Consultant/ Sub Cntr V" 124 Address 130Y- S -L y City_ �_"LLiC# 3t 7 5 Phone# 7 7 L - 36 2-0 <br />GIS Coordinates: X , Y <br />Township <br />WORK TO BE PERFORMED: <br />p NEW NG (CPT, CvEOPROBE, HYD OPUNCH, HAND -AUGER, OTHER*) <br />SOIL BOR W (JLrI -C rz 7— 1K <br />0 WELL # <br />0 *Other 2Y <br />COMMENTS: _ Z )e - <br />v <br />Range Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 5 1, b-- TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE a PUSH POINT (GP or CPT) GROUT SEAL PUMPED: S'Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />Q SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 36' - 64' 0 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 />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Or in�alnncel>, R les and Regulations, and all applicable California State Laws. f� <br />Signed x v'' / t'1 Title/Company <br />Print Name G '2 vE4,1 Date 0 3 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />ApplicationAccepted By <br />Grout Inspection By_ <br />Destruction Inspection B <br />COMMENTS / CONDITIONS <br />— O 2— <br />Date <br />=a -,63i <br />Inspection By <br />KAI <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT I EQUEST # INVOICE <br />yy <br />3D <br />C-57 ✓ WC ✓ -WAIVER_ C-57 Letter of Authorization to sign ermit_ oC_ 9/30/02 <br />A <br />