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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 Eny"TOSmentalealth Department. <br />Assessor's o �s <br />WELL Location Cross Street /�7LQ City 0// Set,14 Zip Parcel# <br />PROPERTY OwneNx zt-)Address � <br />3 jam-/ �GYyeroL.CityZip S n /� hone# <br />C-57 Contractor *4,- 67,&lv�l Address 8,37 sh,C xW City J&e.1- Zip�2�Phone# -47 A - <br />Consultant / Sub Cntr e�DYwe Address City Lic# Phone# <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT GEOPROBE, HYDWPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />SOIL BORING # 0 OVER -BORE <br />0 WELL # 0 PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE /X' MULTIPLE CASINGS? 0 MULTI-LEVEL? 0 WELL CASING DIA: /V4- <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS A/4 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL .ZD TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE / Ozone KPUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: /MAXIMUM FREE -FALL DEPTH IS 30') �N <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: ©dfr-t w�c CXR t <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH v20 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS: SO/tc- at-- <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 I have prepared this application and that the work will be done in accordance with San Joaquin <br />County OrAwgrices Rul nd Regiiiations, and all applicable California State <br />Laws. <br />Signed x Title/Company <br />Print Nam. r)nta <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By 1 Date Issued /�/�/ �z Area <br />Grout Inspection By Date O Final Inspection By /�1% ` Date <br />Destruction Inspection By Date <br />COMMENTS/CON <br />(I- <br />11 <br />ACCOUNTING ONLY: A] D# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />P REQUEST # <br />INVOICE <br />C-57_ WC= WAIVER C-57 Letter of Authorization to sign permit' _ncroachmen -d'oc_ 8/29/02 <br />