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0 • <br />f.A i r'il� <br />3AI�� WELL PERMIT APPLICATION FORM SITE <br />I�1+rj( SAN JOAQUIN COUNTY MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />( RM 11: 04 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br />OCT03 (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 1ppartment. <br />Assesso <br />WELL Location 000 Al/ode &l eeemA _Cross Street Vt C6/- city LD 0 I Zip �0L Parcel# rs "7 } <br />PROPER rI^L, <br />Owner `J I/L Address �/ J �`y/d City J p(,1[.i'?L) Zip Y5 Phone# c;K- ?1-) <br />C-57 Contractor S OU Address lACity '76rUc# Phone#4" gala <br />/ J � <br />Consultant/ Sub Cntryi <br />_ �` f 1,M-fC 1 Ol f r�Address a2$ t? S' drAW*e City c7' 1a 'Lic# Phone# �2-0 1 5W i3 y5 <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />SOIL BORING #T13� a (3Dy 3� 5-c")0 OVER -BORE. DIAMETER <br />,WELL # _MIU{ 1 '2, �y-+-ts0` 0 PRESSURE GROUT <br />0 "Other '2j' '31.q <br />GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />MONITORING <br />HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMERIDRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CP1 <br />)(SOIL BORING (3) <br />0 HAND AUGER <br />0 OTHER: <br />0 OTHER <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE S' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS C- hh YO TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br />DEPTH OF GROUT SEAL 5 TREMIE TYPE TO BE USED:,`AUGERS 0 HOSE <br />GROUT SEAL PUMPED: )(Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS <br />APPROX. BORING DEPTH CBOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED 100 (if YES, list specifications in comment section) <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 Ordinanc , Rules and Regulatio , and all applicable California State Laws. / <br />Signed x Title/Company � 4o <br />Print Name / L� t.s K ��A�� Date .10 /-7 <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: A <br />Application Accepted By. <br />Grout Inspection By <br />DEPARTMENT USE ONLY <br />Date Issued <br />Date Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS 1 CONDITIONS:77,T4777,LTE, P. <br />ACCOUNTING ONLY: AID# 11- f pari <br />FAC# tc�J est �Jd <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY DATE <br />PERMIT! SERVICE REQUEST # <br />INVOICE <br />C-57____- WC -WAIVER_ C-57 Letter of Auth rizati t� sign permit_ Encroachment doc 9/30/02 <br />rM 4, <br />n <br />as M�� ; t 7f1141dt <br />