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FD ( ,r�(;��;�, �_;, WELL PERMIT APPLICATION FORM SITE <br /> � — <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT EHIVTiOid <br /> APR 2 204 304 E. Weber, Third Floor, Stockton, CA., 95202!?) UNIT I�/ <br /> UNIT <br /> i k"VI'�'� ..,..,��..:: i i i'�:-iaJ,IH (209) 468-3449 <br /> F ' 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 <br /> +9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location (!�L` /1 6'Lj"-DIY"x S~ Cross Street V- � -city Assessors�r /r <br /> f City L C dfJ Zip .� ZC, Parcel# !7�r�W <br /> PROPETmc��Ij::!"Address <br /> Owner �k( fc'/ City�(11� �� Zip 1�Phone# q6 <br /> C-57 Contractor �� /d(r Iti-SIra Address C'1,0k, CitvPf� �ttil�yqq�Zipy v5/�Lic#Lj� �lPhon # ( 3 3 �9()o <br /> Consultant/Sub CntrA iCl ,1( ' I ry ljjj/1 �&(A ddress Y37 Afi,,, gr' CityS _Lic# Phone +r D <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> �f EW VVELL/BORING (CPT EOF3ROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE. DIAMETER <br /> [(WELL# 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z"_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: b. <br /> O <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS /V14TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: r <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE P(PUSH POINT(GP or CPT)GROUT SEAL PUMPED:X�''Pm_rt"p <br /> s 0 No (NOTE: MAXIMUM F EE-FALL DEPTH IS 30') <br /> SOIL BORING rr011HAND AUGER GROUT SPECIFICATION TSS K rz 0 <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH y 0 BOLTED TRA F11 C BOX or 0 STOVE PIPE <br /> .5 CONDUCTOR CASING PROPOSED 1r/ (if YES,list specifications in comment section) <br /> CONIMENTS�k ��1 L GG AU� -LLs�t4 <br /> NOTE:E: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHME.a!T PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepareq this application and that the work will be done in accordance with San Joaquin <br /> County arZflesl�ancl R I ns, and all applicable California State Laws. <br /> �� � � ' <br /> � � � oSigned x Title;Compantf <br /> Print Name fL �. rb)1)�V� Dates � T`-Z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �(>Z ('cc �i��Jv��c 5 r <br /> WORK PLAN DATED: 2 DD <br /> Application Accepted By 0 rrf Date Issued H /Z D Area t22-0 <br /> Grout Inspection By 1.(�.v��r�+-. Date ' /S C� Final Inspection By -tel (�r �.r �a Date E' L <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 /> 35a �.oa ZoZ�sS` 4 Z o SR# 3 �� <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc 9/30/02 <br />