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1IF ILE topy <br /> WELL PERMIT APPLICATION FORM SITE ! -- <br /> SAN JOAQUIN COUNTY MITIGATION <br /> �!d4`4fOWEN!Ai, HEAI-INVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> SERVICE UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> 03 OCT - 1 PM Z' I l (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 S,ran <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 6�R!'C-C'r}y ACL 1 CAST/-oi- AgLM �/J�� Assessors <br /> WELL Location. `_[0 W. eteCl��( _Cross Street"a4—city'f rZ/kCY Zip`l 53 46 Parcel# <br /> PROPERTY Owner C irY O r' `V11ZAG Address Sao CityIXA G'{ Zip 153:K.PPhone40L-$31- 46ck'.? <br /> �` 4 / rhone#a/0 0FY525 0 <br /> C-57 Contractor /Address S. d City,�� Zip ic <br /> s <br /> Consultant/Sub CntCleocnctl'nK Co4-5'31 % Addressat011lJebS+ei$1 JIo�F�CityV't!04^a Lic# Phone#_Ste,-663- 4 100 <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERF <br /> N NEW WELL/ :ORI PT E O HYDROPUNCH,HAND AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> []SOIL B # C-t r1 x- 0l6 j a�r oI S -3�4o 3$ []OVER-BORE. DIAMETER <br /> [] <br /> WELL# []PRESSURE GROUT <br /> []*Other r GROUT SPECIFICATIONS <br /> COMMENTS: q So 'l A- -7 *'1- 615 -toi- ny,ro.1,-✓►er+�a� Sa' � Ses-v..+l �, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING []HOLLOW STEM DIA.OF BOREHOLEa•s"[]MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: f1.A <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS rA A TYPE OF CASING: []STEEL []PVC []OTHER: NA <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL--L,I DC TREMIE TYPE TO BE USED: O AUGERS []HOSE <br /> (]AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: []Yes $No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> SOIL BORING [j HAND AUGER GROUT SPECIFICATIONS <br /> []OTHER: []OTHER APPROX.BORING DEPTH 4 fit' []BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED N A (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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x41-11 r� Title/Company SG;cfv�r�5� o <br /> Print Name MATS 61"f—la-z— Date a JGA O 3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: D uj ` Bel--C"07-1 CAJRLj(_C-Z�> <br /> WORK PLAN DATED: 3 <br /> Date Issued Area <br /> Application Accepted By `D rg <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 41o1 6 lllni /OI 3 S D0 5S1 <br /> C-57 V W -WAIVER C-57 Letter of Authorization to sign permit t7 Encroachment doc 9/30/02 <br />