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' o3jW3 12:33T tLf Copy <br /> 5�IWELL PERMIT APPLICATION FORM SITE <br /> J n <br /> //QJ SAN JOAQUIN COUNTY MITIGATION <br /> �t ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT <br /> O IV <br /> A <br /> ✓. 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> / (209) 468-3449 <br /> NON REFUNDABLE PERMIT EXPIRE51 YEAR FRpM DATE ISSUED <br /> Application is hereby made to San Joaquin Countyfor a permit to construN and/or Install the vorK desenbed. This appllwlion is made in compliance pith San <br /> Joaquin County Development Title,Chapter 9.11115.3 and the Standards o�fS�ann JJcaaquin ounty Environmental Health DapartmantAssessors ' <br /> WELL Locatto /per/ (i•// Cross Street r/��"w wity T ZIp <br /> t� r7d 0 ,. y � Parcel#-_-.- <br /> Address � W - <br /> wM <br /> t� C � Phone <br /> PROPERTY Owne 500IRAVt-c10 C5T'.705ZI36 6i6�J )•(I ]64 itV�. Zi AIc# Phono# <br /> C-57 ContractorQL F Address II <br /> O <br /> Consultand Sub Cntr b'f.M f 'BJP - Addrass�,.��'Lf�V SOL . cit rJtG ice Phon '707� <br /> GIS Coordinates:X <br /> y ,Township Range Section <br /> woR( 0 ERF A - R. <br /> FSTRUCTION (choose type below) <br /> EW WELL BORING (CPT,CEOPROBE,HYDROPUNCH, 13/(3R-BORE. DIAMETER <br /> r �OL e O D PRESSURIRGUT <br /> a YELL k <br /> D ROUTSPECIFICA,vr:S <br /> QYr•other I � <br /> Y u/w[ 7,.,7tf <br /> COMMENTS: l$'p� u/a` rvAG/' <br /> TYPE OF WELL IN's ALLATIONTYPE CONSTRUCTION SPECIFICATION$ <br /> p MONITORING HOLLOW STEM DIA.OF BOREHOLE D MULTIPLE CASING$ Q MULTI-LEVEL HELL CASING DIA._ <br /> 0 EXTRACTION D AIR HAMMERrDRIVEN CASING THICKNESS TYPE OF CASING D STEEL D PVC D CTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL I TREMIE TWE TO BE USED: D AUGERS 0 HOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: d Ws D No,(NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> )fJ Chl+6/- d <br /> SOIL BORING D HAND AUGER GROUT SPECIFICATIONS DEPTH <br /> �£ ' <br /> D OTHER:-O OTHER APPRCDC.BORING DEPTH D BOLTED TRAFFIC B(D( Or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list speclications in comment section) <br /> COMMENT$: 06-Mrt( O^' 6JOAV �t'f^I /)*nmj 31r103 -- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify t In r ared this application and that the work will be done in accordance with San Joaquin <br /> County Ord' an es a r�d Regulations,and all applicable California State Laws. <br /> Title/Company, ^----^- <br /> Slgnetl a q/3/Q <br /> - C.rT�'rl , Date <br /> Print Name DEPARTMENT USE ONLY <br /> �����6c.o,P <br /> R /rah SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: 3'1-07 <br /> Area <br /> Application Accepted By <br /> Date Issued <br /> Grout Inspection By. <br /> Oate Final Inspection By Date <br /> Destruction Inspection By Dater - <br /> COMMENTS l CONDITIONS: <br /> I <br /> ACCOUNTINGONLY: AID# FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST p INVOICE <br /> o /08/ 6 3-S sR# Q <br /> 2� f <br /> C-57_ WCC WAIVER, C-57 Letter of Authorization to sign permit nc chmerlt doc— 9/30/02 <br /> -RIP 3 <br />