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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (209) 468-3449 01) AP;; IQ F�'� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 2: 57 <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 9-1115.1'3 land the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location T-7 �'(o+-Jct.o)C4 ioc Kms-+ Cross Street/4,,,,- Ci oc p Parcel#Assessors13 03Cl o <br /> mLn City � �-� Zi 9SzoZ b <br /> PROPE TY / / I ,t <br /> Owner L. <br /> k. ���Ctw�(eS$I�..,Address n/. S' ,, T-L , -1 CitvS4Cx k-to, Zip ZI <br /> Sj Phone# IV <br /> C-57 ContractorGt-agg b..;1(;,g�nstf Address ({oc.x Rood Ci �ncz Zi S 6SG'fo� <br /> / c� II ty/t�ar�' p`�Y S3 Lic#VS�StcS Phone/#y l 3(3-Saco <br /> Consultant/Sub Cntr�r�b.-; Address�a pa r-k:.s S4. City�slornq Lic#RG 61Z� Phone#t_.fo-FJZ5-yg� <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) J <br /> ,%SOIL BORING# S$-3 0 OVER-BORE. DIAMETER <br /> `,g WELL# 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS 0 <br /> COMMENTS: 3- z-f -/o r:.,o Gy L <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLES 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:Y (b <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS------k90 TYPE OF CASING: 0 STEEL )PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL So TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: XYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Po�--f(g-,o( Car^ f-,- F <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH -40' 8OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED IV,::) (if YES,list specifications in comment section) <br /> COMMENTS:Gvc��S -{o of�� 40 — :70" GA o /ao / <br /> NOTE: OFFSITE BORINGS REQUIRE ACC SS 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, ul ions, and all applicable California State Laws. //// �^ <br /> Signed x Title/Comfi �/'� l"pany6 <br /> Print Name Chz, Po Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By /J." �^" Date Issued �j/Z�I L�-/ Area <br /> Grout Inspection By l- Date // Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE EST# INVOICE <br /> ! 8�3 �L �� SR# �c, 3-�� <br /> C-57 WC= nc WAIVER_ C-57 Letter of Authorization to sign permit Echtnent-doc 9/30/02 <br />