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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 <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 !S a i L' Cross Street G ti City '5't C t7Z Zip Assessors <br />Parcel# <br />i <br />PROPERTY OwnerAddress City Zip Phone# <br />C-57 Contractor �' '� t' <br />1 <br />L I (t w Address L7 14 16 City �ip K64 ILic#/ ' ` Phone# 'i14 7 7 <br />FEE INFO <br />Consultant / Sulk Cntr <br />C 6 a Address 136.'e y v City 5la�ic# Y 5 Phone# Z� (i '77Z <br />DATE PERIM / SERVICE REQ T <br />GIS Coordinates: X <br />Y Township Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />0 WELL # <br />0 PRESSURE GROUT <br />0 `Other <br />GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />g,MONITORING <br />.0 HOLLOW STEM DIA. OF BOREHOLE n 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN CASING THICKNESS '. TYPE OF CASING: 0 STEEL ',II PVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY DEPTH OF GROUT SEAL -' TREMIE TYPE TO BE USED: 0 AUGERS &_HOSE <br />0 AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: 0 Yes - 0,No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER:_0 <br />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 x , J Title/Company { = •- t L` v <br />Print Name d� Eft �� "� Date 2 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: �r�Q c, <br />WORK PLAN DATED: 5 - 2 0 - G <br />Application Accepted By. <br />Grout Inspection By_ <br />Destruction Inspection B <br />COMMENTS / CONDITIONS: <br />Date <br />_Date Issues <br />al Inspection <br />Area <br />15- -/6 -03 <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERIM / SERVICE REQ T <br />INVOICE <br />0-03 33 �- <br />C-57_ WC ✓ -WAIVER_ C-57 Letter of Authorization to sign permit -" Encroach-f—doh ` 9/30/02 <br />