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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> i ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> L 304 E. Weber, Third Floor, Stockton, CA , 95202 <br /> (209) 46$-3449 Z9 5:k <br /> NON-REFUNDABLE PERMIT EXPIRES,1 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 with San <br /> Joaquin County Development Title,Chapter 9-1115 3 and1he Standards of San Joaquin County Environmental Health Department <br /> f, ` u L g a l Zip45ayS Parcel# �SS'3a <br /> WELL LocationAssessors <br /> y3 "�r� 8.4'Ne Cross Street City <br /> Ower N w Wf'S__- olQ' Address OPERTYBJ !�T�� City S 11KtfA� zip-9-59 t I Phone# 7y� O <br /> }} I5-n 2- 717510 r <br /> C-57 Contractor CASCIVC pf rjll rl� Address 3Io3� �ME� Cite City CtQ�R4 krlk 71p Luh Phoney# pig- 110 1 <br /> Consultant I Sub Cntr f?'G _Address 37 5 w A D City� if -ice � a7� Phone#\�o��y�o 7 'i'Po\0 <br /> GIS Coordinates X Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL 1 SWORI GEOPROBE HYDROPUNCH HAND-AUGER OTHER`) DESTRUCTION (choose type below) <br /> 11 SOIL BO NG# == 0 OVER-80RE DIAMETER <br /> `WELL# rF <br /> II PRESSURE GROUT <br /> 0'Other ter- GROUT SPECIFICATIONS ' <br /> COMMENTS e,n c WY2 <br /> t5 a c�-obr aa3 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> XIMONITORING , <OLLOW STEM DIA OF BOREHOLE�I , p MULTIPLE CASINGS 0 UIULTI-LEVE=L WELL CASING DIA Z�r <br /> s-,hV P VP <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNE=SS Yo TYPE=OF CASING 0 STEEL PVC a OTHER <br /> VAPOR 13 MUD ROTARY DEPTH OF GROUT SEAL ;� ' TREMIETYPE TO BE USED O AUGERS HOSE <br /> 0 AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPE=D p Yes XNo (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> 1]SOIL 80R1NG NAND AUGER GROUT SPECIFICATIONS ?r 1 A T. > <br /> 0 OTHER 11 OTHER APPROX BORING DEPTH S 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED,„_, &D ,^(if YES I st specifications in comment section) <br /> COMMENTS <br /> MOTE OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ord nances, RuI s and Re u[atiOns, and all applicable Caltfornl tate Laws <br /> l7f <br /> Signed x (� Title/Company flO it Q!o <br /> Print Name `V <br /> DEPARTMENT USE ONLY �� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: • 1 <br /> iew <br /> WORK PLAN DATED' #4-1 -0 <br /> Application Accepted By Date Issued ���� Area <br /> Grout Inspection By Date Fnal Inspection By Date <br /> Destrucdon Inspection By Date <br /> COMMENTS 1 CONDITIONS <br /> ACCOUNTING ONLY RID# FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY I DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Z.9 d <br /> gel 30 40 Vr� -�� S R# 003 11 o <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign pertnrt Encroachment dac 9/30/02 <br /> Q m <br />