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WELL PERMIT APPLICATION FORM <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 . <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Cos' D s�G <br /> Spplication 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 /> oaquin County Development Title,Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> Assessor's <br /> WELL Locatlon J'72,5 park,o 51 Cross Street n irk S-6 City Zip Parcel# <br /> �ROPERTY Ownerrt e� StOtk��_Address o�- W4,i City Zip Phone# <br /> C-57 Contractor Address a <br /> 0".2-T S}"��-'�� I Cit}tSboC�fQn Zip Stas Llc#�SouTP�one# <br /> tonsuitant/Sub <br /> ontractor Ph' . Cc' Address t!a Oc6-1 /x—J la"AL Cdy&rl�-�.bi4 Lic# Phone# 6/`f" L 1-154`7 <br /> .Z1lti.,5 Cts.3e- <br /> CORK <br /> S Coordinates X 9 6 * A[ Y !Ll- 17 i� Township / Range i! E _Section_ /O <br /> TO BE PERFORMED <br /> ,XNEW WELL/BORING( gAiRING <br /> HYDROpU1ICH,HAND-AUGER,OTHER") Q DESTRUCTION(choose type below) <br /> #�T R OVER-BORE <br /> �, WELL# ©PRESSURE GROUT'Other Grout Specifications <br /> COMMENTS <br /> WXYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Na MONITORING p HOLLOW STEM DA OF BOREHOLE MULTIPLE CASINGS?Q YES ©NO WELL CASING DIA <br /> r TRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING p STEEL 0 PVC []OTHER <br /> 1APOR MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED {I AUGERS p HOSE <br /> p AIR SPARGE XPUSH POINT GROUT SEAL PUMPED p Yes Q No (NOTE. MAXIMUM FREE-FALL DEPTH IS 301) <br /> 'SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> 'p OTHER n OTHER APPROX BORING DEPTH t]BOLTED TRAFFIC BOX ori]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here) <br /> *COMMENTS r w 5 a c da— clo cf o i K S� I•K <br /> ' NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 and Regulations,and all applicable California State/Laws. <br /> Signed x �..� k D-h--/ TdlelCompany PN `r ✓✓r C c/S <br /> ' <br /> Print Name_ i�F��C ,t,�i.•�c <br /> DEPARTMENT USE ONLY <br /> / <br /> SITE MAP IN UNIT IV FILE,ADDRESS: l �• �r <br /> WORKPLAN DATED: <br /> 'Application Acoepted B Date Issued Z~ Area <br /> PR Y <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> OMMENTS 1 CONDITIONS & 40, Yb .3 ��Z... <br /> ACCOUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DA . ' PERMIT!SERVICE REQUEST# INVOICE <br /> I 89 az 3 3•s 0 O l <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit le' Encroachment doc 1/25/02 <br /> 4P a&go 0 <br />