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Title/Company 0,02:71cd??..1" 0747, <br /> Date /3( <br />DEPARTMENT USE ONLY <br />oa <br />Signed ; <br />Print Name <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 /> <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 />,,,...7.,,,, <br />1 <br />Assessors ) ,3 <br />WELL Location 37(35 Tracl i3lvot Cross Street ERA) y P.05- City Tracy Zip 73,X7 Parcel# 0 /?/ 70 0 <br />- <br />PROPERTY Owner EtU 41 eutw7riS-0 11..C. Address /V 4046 8441 City ge$70,7 Zip 77656 Phone# <br />C-57 Contractor6115 Dr I ii lin Addres450 HOWE Rd city/A.0*a zip79553Lic#45/65 Phonedot5-3/3-5/3 60 <br />Consultant/Sub Cntr Cambria Address P.O. gox 2 5'1' City SO/10.41.4 Lic# — Phone# 707 33 -A1V <br />GIS Coordinates: X <br />Tj4n <br />,// Range Section <br />WORK TO BE PERFORMED: <br />(CPT, GEOPROBE, HYDROPUNCH, HAND4y4NrOpieT) <br />P r RMIT/SERVICES <br />HEALTH <br />%DESTRUCTION (choose type below) <br />H OVER-BORE. DIAMETER <br />g NEW WELL / BORING <br />[] SOIL BORING # <br />[] WELL # GROrRESSURE GROUT 4 rip Ca Oi <br />SPECIFICATIONS [] *Other ENVIRUNMENT <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS / It <br />DIA. OF BOREHOLE ? I] MULTIPLE CASINGS [] MULTI-LEVEL WELL CASING DIA: 6 <br />CASING THICKNESS TYPE OF CASING: XSTEEL [] PVC [] OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [] AUGERS [] HOSE <br />[] PUSH POINT (GP or CPT) GROUT SEAL PUMPED: XYes n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />[] HAND AUGER GROUT SPECIFICATIONS C.444A.ej/1.19AlA7 <br />[] OTHER IAVikitOtAAA APPROX. BORING DEPTH / 1.5 [] BOLTED TRAFFIC BOX or [] 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 Ordinance les anfl,Regulations, and all applicable California State Laws. <br />TYPE OF WELL <br />[] MONITORING <br />H EXTRACTION <br />[] VAPOR <br />[l AIR SPARGE/ OZONE <br />[] SOIL BORING <br />MOTHER: p(/ <br />INSTALLATION TYPE <br />[] HOLLOW STEM <br />[] AIR HAMMER/DRIVEN <br />[] MUD ROTARY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By 1jk,"/":t-" <br />Date zIN(0-3 Final Inspection By Ct.14/1,Nrcin Date <br />Date <br />Date Issued 2110(o <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: G Sitr—te- Acrat <br />ACCOUNTING ONLY: AID# <br />I <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE RMIT / SERV # <br />3S001- 60- 60" <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br /> <br />Encroachment doc <br /> <br />9/30/02 <br />