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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 UMbINAL <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 />�/ / �, // 1 Assessors <br />WELL Location 257-25 Co6en irti �L _h x1 v"k Cross Street P �ynb��� /ta,JCity STv��� / o� Zip Parcel# <br />PRO ER.7 ^ (rr��s�s LLG c�o <br />C-57 <br />D0, I(..9'47 <br />(� l l U <br />s1yo has E 64L -4l, ts" City e4oc�� TA Zip 77a4 Phone# <br />_C, 05-7 <br />dress`15D %�vc 4,.c,,je�e City / e Zip4KS' Lic# Phone# 415-3/3-58oa <br />Consultant:-. C� AddFs Z-jn R&'- Phone# 767- ?33 -236)7 <br />GIS Coordinates: X <br />Y <br />Township Range <br />Section <br />WORK TO BE PERFORMED: <br />AID# <br />NEW WELL / BORING (CPT, 0 ROB) HYDROPUNCH, NQ -AUGER, OTHER') p DESTRUCTION (choose type below) <br />�Gcy''ohhc)) <br />PE CODES <br />�SOILBORING# �-I f 6-/`f aOVER-BORE. DIAMETER <br />AMOUNT REMITTED <br />WELL If M w--1 a PRESSURE GROUT <br />REC'D BY <br />a `Other GROUT SPECIFICATIONS <br />INVOICE <br />COMMENTS: <br />v� <br />6-�� sR# o�30- <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �1 <br />MONITORING STEM DIA. OF BOREHOLE I0'1 a MULTIPLE CASINGS [I MULTI-LEVEL WELL CASING DIA: y <br />�X'HOLLOW <br />U <br />o EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS AMA 5,4.TYPE OF CASING: 0 STEEL XPVC a OTHER: <br />o VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL y TREMIE TYPE TO BE USED: O AUGERS HOSE <br />o AIR SPARGE/ OZONE XPUSH POINT (GP or CPT)GROUT SEAL PUMPED: n Yess )) No JNOTE: MAXIMUM FREE -FALL DEPTH IS 30' <br />SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br />OTHER:_0 0 OTHER APPROX. BORING DEPTH ZO ;BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED �[J (if YES, list specifications in comment section) <br />� <br />COMMENTS: So. 1 __20 <br />NOTE: OFFS IT ORINGS 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 Ordina^ce!�,.ftu std 3MIations, and all applicable California State Laws. <br />Signed <br />Print Name <br />TitlelCompany r" "'r -aK-40-t-/ / <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 5-2_8_0 <br />Coo x-� CW 3 P-.)wd — LoP <br />Application Accepted By Date Issued ' <br />Grout Inspection By Date Final Inspection By. <br />Destruction Inspection <br />COMMENTS / <br />Date <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PER ST # <br />INVOICE <br />1t?a- <br />6-�� sR# o�30- <br />C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit oachment doc � 9/30/02 <br />