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�I�1�iN�L <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` j <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, hapter 9-1115.3 and the Standards of San Joaauin County Environmental Health Department. <br />// ��/ Assessors <br />WELL Location Cross Street - -- (ity 6-2yjff�2 _Zip Parcel# <br />L/ <br />PROPERTY } ./ "� yy � / / , �l 60 / ��—p �/ <br />Owner/ O� t� � Address �� �� d��` �f City Z Zip 30 Phone# Y✓ o —2 -d yy,, <br />C-57 Contractor_ �( Address 1616 5N, S C4 Zi 1G ic#Z1L/q__% hon /6) �/©-d <br />_ d <br />Consultant / Sub Cntr ��G %��— P/�eiXf Address 1� i� yi�jZ� City �✓JZ>� Lic# — Phone -> eft lj,/ SJ <br />GIS Coordinates: X 'Y , Township <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING <br />0 SOIL BORING it <br />'561E—'Other <br />COMMENTS: <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHE <br />"DESTRUCTION (choose type below) <br />'OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS ✓1 fi't; 0.0? 7 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING *OLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI -L ELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS '�?,�, elf 0 TYPE OF CASING: 0 STEEL $PVC 0 OTHER <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: XYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS a} w'ot7� r�'vYIP/1 >I <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 BORI GS 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 x <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: ��— <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection B <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />DEPARTMENT USE ONLY <br />Date <br />PE CODES FEE INFO I AMOUNT REMITTED CHECK # <br />27 o v� l 66, 12---;) a/ <br />nal <br />RECD BY I DATE <br />_412 145' <br />UEST # I INVOICE <br />C-57 \/ WC`! -WAIVER_ C-57 Letter of Authorization to sign permit_ oac 9/30/02 <br />