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Date <br />Oat <br />S3/24/2B03 14:46 2094671118 AGE STOCKTON PAGE 03 <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 />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 ...21-/)" 517 ...ovy',...cross Street/ <br /> ,n <br />ity,51itie)/240 Zip q <br />AssesSOr <br />:,..2ii-2_Parcel# 13 - (-CO -OS- <br />1 • :s <br />PROPERTY Owner 5./nW -se alLq"Address'4XV-- cgfq.Y-/-jr5V.V.4"-Qity„.5-Nde_d.a.„ zipSzpi2phonats2o9 rY3 <br />C-57 Contractor 6, 4 "ILL—Address 11-10„kie, /e4s)-e,_ City /114,v-6:4,1 /4/e 1716- Licege 567 ph or j.25- <br />Consultant/Sub Cntr Address 7 .61i,e41,0 city.574 Lic# Phoneiali'? 16 1e.66 <br />GIS Coordinates: X Y , Township <br /> <br />Range Section <br /> <br />L"N • <br />[... <br />fliLfl <br />MAR 2 4 Z003 <br />ENVIRONMENT HEAL). <br />PER MIT/SERVlCES <br />SITE <br />MITIGATION <br />UNIT IV <br />WORK TO BE PERFORMED: <br />)1,NEW WELL / BORING ( CPT...GEOPROBE, HYDROPUNCH. HAND-AUGER, OTHER') <br />0 SOIL BORING # <br />0 WELL # <br />'Other: Grout Specifications: <br />COMMENTS <br />0 DESTRUCTION (choose type below) <br />61 OVER-BORE <br />0 PRESSURE GROUT <br />Signed x <br />Print Name frt)i- <br />TYPE OF WELL <br />0 MONITORING <br />0 EXTRACTION <br />VAPOR <br />CI AIR SPARGE / Ozone <br />p-SOIL BORING <br />0 OTHER: <br />*COMMENTS: <br />INSTALLATioN TYPE <br />0 HOLLOW STEM <br />El AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />USH POINT <br />0 HAND AUGER <br />0 OTHER <br />SdI <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF 5OREHOLEh MULTIPLE CASINGS? 1:i MULTI-LEVEL? U WELL CASING DIA: AM' <br />CASING THICKNESS A41* TYPE OF CASING: El STEEL. 0 PVC 0 OTHER: /V* <br />DEPTH OF GROUT SEAL ),0 TREMIE TYPE TO BE USED: /0"AuGRS 0 HOSE <br />GROUT SEAL PUMPED: ngYes El No4ifslOT • MAXIMUM FREE -FALL DEPTH JS 30') <br />GROUT SPECIFICATIONS: ;Peg-- <br />APPROX. BORING DEPTH / Ja FM/ U BOLTED TRAFFIC BOX or ti STOVE PIPE <br />n CONDUCTOR CASING PROPOSED? A//1 ( if YES, list specifications here): <br />e/ - <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, R les nd Regulations, and all applicable California State Laws_ <br />Title/Company C-1-711)b <br />Date .2 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: .2 .2 <br />WORK PLAN DATED: -25- cr---(c322,ae -2r5Z2-, <br />Application Accepted By (AN IA.A.Nvo't." <br />Grout inspection By <br />Destruction Inspection By <br />COMMENTS ! CONDITIONS. <br />Date Issued 3(2 SI 0 <br />Are Final Inspection By .4>A4AA-04-1/4. Date qa / C)) <br />ACCOUNTING ONLY: <br />t <br />AiD# <br />6R DaX-3 1 q <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE PERMIT! SERVICE REQUEST 0 <br />3 co ( .,(-... tl_qL_ _. _ /R. .2..1.....,......_ <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02