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0 <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <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 />g 1 ',/ "�,`� ,t Assessor's <br />WELL Location `lj 0 g/li�/�vr// Cross Strtr/e/est`_City s Zip Parcel# <br />PROPERTY Owner ��J�/LJP�f (\ Address// 7 y !/�� A41L City Zip hone# <br />C-57 Contractor /�/ /LQX/�' ®Gress �p ( /� City Zip Lic % !o1 hone# <br />Consultant / Sub Cntr�� (-T� Address 13 7,J�leo City `� Lic# Phone# <br />GIS Coordinates: X , Y , Township Range <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />0 SOIL BORING # <br />0 WELL # <br />*Other: <br />COMMENTS <br />TYPE OF WELL <br />INSTALLATION TYPE <br />r <br />UMONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE / Ozone 0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER: <br />0 OTHER <br />Grout Specifications: <br />Section <br />;kYESTRUCTION (choose type below <br />UOVER-BORE <br />PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 MULTI-LEVEL? 0 WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: T <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH <br />0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />,� CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS: //f�/�'�'S/ �&/-3Z;I&, 6*U <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I hereby certify that 1 happr red this apppe lication and that the work will be done in accordance with San Joaquin <br />County QFdh)ances, les an egulation,*, and all applicable California State'Laws. 4 <br />Signed <br />Print <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Title/Company LZ <br />DEPARTMENT USE ONLY <br />Application Accepted By , L .� " v Date Issued_ <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS /COND <br />A <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATIE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />3 2 <br />.0 <br />2� <br />1,"0Z 0 2 <br />7 <br />C-57_ WC WAIVER_ C-57 Letter of AuthorlZa to sign ped mit Encroachment doc_ 8/29/02 <br />