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PP�(M SEG <br />IS. <br />MP �O ovN <br />Y010 <br />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 Joa qujn County Environmental Health Department. <br />Z� Assessors l <br />WELL Location V. ` <br />Q Y Cross Street ��L�- City �� Zip X15 3C Parcel# <br />Owner [ &h11tAddress 7 7S/ ]'�D_� Pjy1 City 6-4kO Zipq53% <br />�Phone# 6I <br />'' �� Q ••\S� q Y <br />C-57 Contractor/` 114 -S, ko Address q5a ( kJ C' My)CZZipj�ic#6511�aPhone# /Z'J 313'-!�9r)60 <br />Consultant / Sub Cntr Servs & li, Address �h3W�T�City� ic# 7 Phone# S3'06 76 -60 a <br />GIS Coordinates: X YTownship �5 Range Section 27 <br />ORK TO BE PERFORMED: <br />NEW WELL / BORINGCPT, GEOPROBE, HYDRgPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />SOIL BORING # C S CQT' t� [] OVER -BORE. DIAMETER <br />n WELL # 0 PRESSURE GROUT (l�l <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE/XPUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes [] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30'} <br />`-SOIL BORING [] HAND AUGER GROUT SPECIFICATIONS <br />[] OTHER:_0 OTHER APPROX. BORING DEPTH <br />[] 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 />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ord' antes, Rules a Re lotions, and all applicable Califorl5tate Laws. <br />Signed x� <br />Print N e e 0 I (� Date 2 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: IJ L 00 <br />WORK PLAN DATED: I.D.. 131 o3 <br />Application Accepted By Date Issued -5/y 40 Area -I-) <br />Grout Inspection By Date Final Inspection By Date Lv <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# �% a <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SER INVOICE <br />5111,Lf SR# <br />C-57^ WC --WAIVER C-57 Letter of Authorization to sign permit— Encroachment doc_ 9/30/02 <br />