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flECE[U WELL PERMIT APPLICATION FORM ORIGINAL <br />SAN JOAQUIN COUNTY MITIGATION <br />MAR 10 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br />ENVIRONMENT HEALTH (209) 468-3449 <br />PERMIT/SERVICES <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 />WELL Location �j�Pik t� Assessors <br />D Cross Street City ��� Zip �5 I Parcel# <br />PROPERTY Owner CL T7 D1 S fr( K Address City Zip Phone# <br />C-57 Contractor Q�� I �I/ Address 6d< </ //a CityZSr/{ Zi6 L4f Lic# Phone# `1',t(,,- 177 -4l ev <br />Consultant / Sulp Cntr =1" c.' ✓t .t- Address 60tc ' Z CitvsRIC 9'/ Lie# 3\i 7 Phone# Z(-�- ` 7 % 2 -.?62c <br />GIS Coordinates: X Y Township Range Section <br />PE CODES <br />WORK TO BE PERFORMED: <br />AMOUNT REMITTED <br />i] NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCT!ON (choose type below) <br />PE MI QUEST # <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 "Other GROUT SPECIFICATIONS <br />SR# CSD 3�6 <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />D MONITORING a HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS . -(c TYPE OF CASING: 0 STEEL a PVC 0 OTHER: <br />R <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 25' TREMIE TYPE TO BE USED: D AUGERS p HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: 0 Yes ;glNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />0 SOIL BORING 0 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 Ordlinan�jces, u es and Regulations, and all applicable California State Laws. / , <br />Signed x_ b�c�t � '^ Title/Company 1J ��- lam' �. <br />Print Name V c -j -b �- r C,(4j e-e—L4 /J Date 21 ZU16 -3 <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 6-- 2-"f <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued_ <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />OL <br />ACCOUNTING ONLY: AID# FAC# 7 <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY DATE <br />PE MI QUEST # <br />INVOICE <br />SR# CSD 3�6 <br />C-57 v' WC a -WAIVER_ C-57 Letter of Authorization to sign permit �`--Encroachmen#-doc= 9/30/02 <br />