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WELL PERMIT APPLICATION FORM SITE <br /> . SAN JOAQUIN COUNTY MITIGATION <br /> l ` ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> i 304 E. Weber, Third Floor, Stockton, CA , 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Application is hereby made San Joaquin County for a permit to construct and/or install the work described This application is made in compliance wEth San <br /> Joaquin County Development Tithe..Chapter 9-1115 3 and1he Standards of San Joaquin County Environmental Health Department 1 (� <br /> WELL Location 737 W r� �ArrNCT Cos Street City L x'01 Zip 9515 Parcel#re �55�3� -•i J <br /> PROPERTY C40 G,} rtooA'` ICe714 �^ 1 , W 90 — <br /> Owner NrmW w1=s- nIQ� f Address_ '03/ S .1Se- - CEty_SAJ- AA1Rn10 Zip 95&f YPhone# b �y3 r q <br /> C-37 Contractor<AS�E Ard lin Address %3a ' n�A4}� zE -- Lich-717510 <br /> psi OPhone# <br /> A, <br /> On►cc C►rc.l e city cP � p <br /> Consultant/Sub Cntr A, Address 557 S 4 qty AD City SToCdta-Liw QZ? 7 Phone# 2o�f �/ '�Ao 10 <br /> GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> "EW WELL.!BOR G GEOPROBE HY❑ROPUNCH,HAND-AUGER OTHER) d DESTRUCTION (choose type below) <br /> -11fl17 SOIL BO NG# Q OVER-BORE DIAMETER <br /> `WELL# Q PRESSURE GROUT , <br /> Q■Other -- GROUT SPECIFICATIONS <br /> COMMENTS 1 ?n 4v+r, 2-9e) <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA OF BOREHOLEfj_L Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA zi► <br /> a <br /> s,�i cp-4k <br /> Q EXTRACTION 0 AIR HAMMER/❑RIVEN CASING THICKNESS Y D TYPE OF CASING Q STEEL. PVC Q OTHER <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 3 f TREMIE TYPE TO BE USED Q AUGERS ) HOSE <br /> AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED Q Yes XNo (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS o r 1 A T t- <br /> Q OTHER 0 OTHER APPROX BORING DEPTH, 50' Q BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED Ayo (sf YES list specifications in comment sechon) <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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord nances, Rui s and Re ulatlons, and all applicable Californl tate Lawsr� }} <br /> Signed x Title/Company �! LE Z�, G <br /> Print Name irl ;v1 `V /� Date <br /> 1s <br /> DEPARTMENT USE ONLY <br /> r �� ® •: r <br /> SITE MAP IN UNIT IV FILE,ADDRESS. (0 <br /> WORK PLAN DATED' <br /> Application Accepted By \ Date Issued ` Area <br /> Grout inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS <br /> EAOUNTING ONLY AID# FACO <br /> AIIIIII ODES FEE INFO AIMOUNT REMITTED CHECK# REC'D BY DATE PERMIT l SERVICE REQUEST# INVOICE <br /> 9 o r 30+0 CIS -�-- sR# W 3 `��o <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign perr6 t,Encroachment doe 9/30/02 <br />