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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />IJ 11 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />N - 5 2004 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />MITIGATION <br />UNIT IV <br />im (209) 468-3449 <br />ENVIRONMENT HEALTH <br />t� TQC R\/ (;F� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application isPh&b�lrf►b'd�t 12 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 />Assessors <br />WELL Location/ y FZ/ i -i 17o .25r4e-/tA �Cross Street City /1gf- 11r- of Zip gs334' Parcel# IV A <br />PROPERTY <br />Owne&rkyc L�dZ-, sf �ry�ws y Address/97th GiwY ✓ 4.A -ti Citys%cAL oh Zip9S,Zd/ Phone#249-9y8-75y) <br />C-57 ContractorT>(.,� �v -sk 1z,,,Ac AddressW// AA Cep 1�v/ � t CityW, � e- ip 9164 Lic# ( 7 ) Phone# F1.1 7/ 1174 <br />Consultant /Sub Address39//. w.Cas. 7t✓/ An Cit�k/..S4cvar c# Phone# tel/( -31 / l <br />GIS Coordinates: X Y Township 1 S Range -7 Section.SW k - e.o 3 y <br />d-. ,2 S 7� N W V9 Sec. 3 <br />WORK TO BE PERFORMED: y <br />-SNEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />RSOIL BORING # OM 'SAO (-Z. /o fad) 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other /53 hAMG/ IQ05 t-, 3.o F) GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING HOLLOW STEM DIA. OF BOREHOLE y,, 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 TREMIE TYPE TO BE USED: 0 AUGERS 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 />SOIL BORING `HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed <br />Print <br />Title/Company,Z,. <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: � <br />WORK PLAN DATED: 14- Z4 --0 3 <br />Application Accepted By UE <br />Grout Inspection By Date Final In <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />/20 Rol <br />Date / ac -a', '- ,2003 <br />Issued 1 — o �/ Area 616 <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT/- QUEST # <br />INVOICE <br />C-57�/ WCC WAIVER C-57 Letter of Authorization to sign permit" C 0' 9/30/02 <br />