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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 Environmental Health Department. <br />/- Lr%�Cr (.tiG S-7 l 7 -74 � -���" `Q�, S4C Assessors <br />WELL Location Q N E Cross Street City Zip Parcel# <br />_sem c a nr7u14 'e 7746;^ qis S -y vvi7 01" L L) L5 vO UWA L ✓V �,7 q q j /�--G (,L�G Z3�S Wl4W S �DJ <br />�Z3PROPERTY OAddress S !/%7E City C Zip Phone# 7ZS <br />,571z2 -(o6 U vt ��q4r-&7/C-57 Contractor AddressCitLy�✓ ic#Phone# <br />Consultant/ Sub Cntr f�14"VC�OVkddress City Lic# 5 i?O % Phone# 1 /7 ]Z i S71 <br />C,� <br />GIS Coordinates: X Y Township Range Section ISO <br />-Q <br />WORK TO BE PERFORMED: � <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) ,A DESTRUCTION (choose type below) <br />0 SOIL BORING #t VER -BORE. DIAMETER <br />0 WELL # '.PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS Alell�i G LL"' <br />COMMENTS: s /S.BUG <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING (4) 0 HOLLOW STEM DIA. OF BOREHOLE3rO'L 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />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 D TREMIE TYPE TO BE USED: 0 AUGERS XHOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 1V6'4 -T C e"n Z=l-r <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; �' i �1n�c Ci c. mak- <br />NOTE: OFFSITE BORYNGS 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 />Count Ordinances ules a d Regulations, and all applicable California State Laws. <br />County <br />%li✓G rr'� <br />Signed x /!�Z Title/Company /n/e <br />Print Name /' ` V1- a 6-e-4Date gl2 %[/ <br />&"�— <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: a,,, 4,. -1 , �LD O r <br />U <br />Application Accepted By ljk Date Issued 0 f aq/D S Area 997 <br />Grout Inspection By <br />Destruction Inspection By <br />Date Final Inspection By <br />COMMENTS /CONDITIONS: t.11O `,,{e , (14,1,e 2 - <br />Date q/23/o <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE ODES <br />FEEDNAO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />MIT L EQUEST # <br />INVOICE <br />35.v <br />'96° <br />33 �� <br />- to 03� <br />!�� <br />%ami o� <br />SR#J1�Oq �7 a-0 _'\, <br />C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit\- -Encroachment - doc 9/30/02 <br />