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APIPLICATION FORM <br /> 11VELL PERMIT <br /> SAN JOAQUIN COUNTY <br /> SITE <br /> oc mrr� �hON <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 EM29w <br /> , �j1��EALTN <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 1115.3 and the Standards of.San Joaquin County Environmental Health Department. <br /> $�fva2�'1 _ Assessors , <br /> • ��`O d�� J6 uT� (D ross Street Cs�' 'L�'� City i�`�t. Zip Parcel# C f'f' o <br /> WELL Location <br /> B 8 As,& CorreLl W&,y <br /> PROPE�T.Y Address ZD —r�y }4ol cv ��J� 5 Phone# (2-,P9)�� <br /> J--� 00 <br /> caner i � d F �f�Cy iv CityR&CYZip <br /> t r r'2 ��e 5 -+,n Address 9.50 �oc ©ct City �rf�nt7 Zip7g55:3 Lic#�93145 Phone#(925)3)3 �96® <br /> C-57 Contrac o <br /> 3800 L �' Ade. Stz 2l�it �eP-Ar`'1e�et.ic# Phone# i 1(6)17 q_g?00 <br /> Consultant/Sub Cntr SA I C— Address 1 Y <br /> CeAQ.-I C(()56k 102.0 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> .W RK TO BE PERFO <br /> EW ELL BORING (CPT,.GEOPROBE,`'HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL BORING# o OVER-BORE. DIAMETER <br /> WELL# H PRESSURE GROUT <br /> [] <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING OLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: NA <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS N A TYPE OF CASING: 0 STEEL []PVC 0 OTHER: <br /> VAPOR <br /> Q UD ROTARY <br /> DEPTH OF GROUT SEAL Of b"%f eTREMiE TYPE TO BE USED: 4UGERS HOS f-p>'30-� <br /> (POINT GP or CPT GROUT SEAL PUMPED: Yes n No (NOTE: MAXIMUM FREE-FALL DEPTH S 30'), <br /> a AIR SPARGE/OZONE PUSH )'SOIL BORING a HAND AUGER GROUT SPECIFICATIONS C� � �� � (:5' <br /> © b&+,c�,+"6 <br /> OTHER: 0 OTHER APPROX.BORING DEPTH 25 4"0 50 .� []BO TED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING-PROPOSED , (if YES,list specifications in comment section) <br /> COMMENTS: 7�940 <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 an Reg lations, and all applicable California State Laws. <br /> � I C'fix�-F Title/Com an <br /> Signed x p Y <br /> Print Name V� �1/1�1 S Date v <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS. B"vat /4k=dw <br /> • <br /> -WORK PLAN DATED: U t4 3 <br /> Application Accepted By <br /> Date Issued r�� d � Area dlog <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 /> _ <br /> tD SR# <br /> C) <br /> 3e0 5:5�5 <br /> R C-57 Letter of Authorization to sin ermit_..Encroachment doc____ 9/30/02 <br /> C-57._ WC� WAIVE _.. 9 p <br />