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R � W E P <br />WELL PERMIT APPLICATION FORM <br />,JAN 0 7 2004 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />PERMIT/SERVICES (209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <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 />SSS C.1 5T� �e/iRiNuACi S�37ry Assessors 370-0 <br />WELL Location Cross Street City " Zip 9 Parcel# ;L 3_ <br />PROPERTY COX `F C v` X JT) R. <br />Owner :J R N t cE Qj(ZDu�N Address wol.-WiF D Ciiy S/ IFFttN/i Zip��f, Phone# O <br />C-57 Contractor -14VJ DRi( -(4 drass <br />d 126 moose 41aL City4sLFf,Ajzip(-, 641LIc# Phone# /16-777���00 <br />Consultant/SubCntrAl rtN0*ddress Y'Z L 10- ST• city RACi C# 5- q Phone# �9 ,95 <br />V- "l CE5 1--vC, <br />GIS Coordinates: X , \r I Township Range Section <br />WORK TO BE ,,-'ERFORMED: <br />0 NEW WELL / BORING <br />0 SOIL BORING # _ <br />0 WELL # <br />0 'Other <br />COMMENTS: <br />(CPT, GEOPROSE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />DESTRUCTION (choose type below) <br />{. VER -BORE. DIAMETER <br />PRESSURE GROUT <br />vROUT SPECIFICATIONS <br />SEES` 9 uc c0O.a <br />TYPE OF WELL INSTALLATION TYPE ." CONsTRAFCTjQN SPECIFICATIONS_ <br />`&MONITORING HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />d <br />Q EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />Q VAPOR MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS - H A 9-D 'le''-; I `­' �g Q ` O L ' <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH r B GG -S 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: WoR�L gc- 4 DO t_ -E 1T) 'r -o fZ J AtJ OA F-'( 2o04 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />M <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, Mules and Regulations, and all applicable California State Laws. 1� ,v c' <br />�• tet(' I JYlq;.4 &-E l-7% VL�21 C;11 % Fr4 lid 0♦ ,'v A4,F,'IT" L <br />Signed x Y ��'>`�` Title/Company <br />Print Name - T�' f `t �O c l/ N i l Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: S L o0 <br />Application Accepted By_ Date Issued Area <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />I DATE PERMIT # <br />I <br />INVOICE <br />/y, SR# DD3�`j7 D <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit- _ 9/30/02 <br />