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WELL PERMIT APPLICATION FORM `\S <br /> 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 <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'.Zr7 v//. "A// 04CU/KJ ,,CV- Cross Street /iLt yL- �'jfj� GG Assessor's <br /> City ��'0%. Zip T.T JW 2--Parcel# <br /> PROPERTY Owner 44444 W1 L Address (O AO XV, -mow 7- p <br /> /�// //�� CDUmarL y ' ziP J'4 Phone# 9i// LG// <br /> C-57 Contractor�Gr Address J=V � `f 4A'r' ,S <br /> --�-'----q�C�ty ,�=L�ZiP !�1'VLic#IpQOL2 Phane# Y�7-/ldl <br /> Consultant/Sub Cntr � AddressI�7 .--5�, .l 'YJ/Y�Ci 1. <br /> — � ry.S«<yl. Lic OL Z, Phone# <br /> GIS Coordinates:X.,Y ,Townshi <br /> P Range Section <br /> WORK TO BE PERFORMED' <br /> Q NEW WELL/BORING(CP',T/GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) <br /> jl SOIL BORING#_$-/ g.Z Q DESTRUCTION(choose type below) <br /> Q WELL# Q OVER-BORE <br /> 'Other: <br /> COMMENTS Grout Specifications: Q PRESSURE GROUT <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE ' <br /> Q EXTRACTION rL_MULTIPLE CASINGS?QMULTI-LEVEL?Q WELL CASING DIA: FZL <br /> Q AIR HAMMER/DRIVEN CASING THICKNESS NA- TYPE OF CASING: Q STEEL Q PVC <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL_ e2p / Q OTHER: N/Y <br /> Q AIR SPARGE/Ozone PUSH POINT TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> GROUT SEAL PUMPED: QYes "o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: t'oA/L,r,'d �cfvyTry� <br /> Q OTHER: Q OTHER APPROX.BORING DEPTHAQ / <br /> Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> "7� CONDUCTOR CASING PROPOSED? 40- (if YES list sp cifications here): <br /> *COMMENTS:_ i✓(✓j FUQ (/naf1111/-b/U�1'r L'hJ'T OF LIsT �C U26 A/' � <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 /> I hereby certify that I have Drel3ared this application and that the work will be done in accordance with San Joaquin <br /> County Orces, les an Regula tio s all applicable California State Laws. <br /> Signed ,,"-rte Title/Company ✓/r✓E �i�'S/�t7�� <br /> Print Name 1c/in Date 9 $d dL <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued <br /> Grout Inspection By Area <br /> Date Fnal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: d ®Sjti ae V� e <br /> R <br /> ACCOUNTING ONLY: AID# <br /> T <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57_ WC--WAIVER— C-57 Letter of Autho nation to sign permit_Encroachment doc_" 8/29/02 <br />