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WELL PERMIT APPLICATION FORM SITE <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 CV A f <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 <br /> � <br /> ppltcation 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 Location 11 I'7 Soi._{k �teo, ,st Cross Street I, L�d St. _City :?,UC,6[ a, Zip Parcel# LG S-07 2- <br /> z ' <br /> �ROPERTY Owner 5��� re- a iso n Address $7T t 1ae.,tu s s de— City 5 *A Zip 9�Phone# <br /> �1 I2A.CA0 <br /> C-57 Contractor CrG1 <br /> tS .a Je Address 341,2— 0.•w-c eretJc City_Corda�� Zip9 74L Lic# 7dT I Prone#9i6'43 8~ ���9 <br /> 'Consultant I Sub - Zi o <br /> Contractor Ph;1i? 5.r✓.Ce S _Address �s f S••�d,b«K City Cor+-4&#A. Ltc# Phone# 91 Y-2-Sl <br /> .x11."Ods LL 4 <br /> GIS Coordinates X, ,3'7'p 591 N Y_17-I s 17 'ri,J Township I A) Range Section /D <br /> WORK TO BE PERFORMED <br /> EW WELL I BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') Q DESTRUCTION(choose type below) <br /> []SOIL BORING# a OVER-BORE <br /> , WELL# Vw•1 - f []PRESSURE GROUT <br /> Other Grout Specifications <br /> COMMENTS <br /> iTYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING HOLLOW STEM DIA OF BOREHOLE'�'�MULTIPLE CASINGS?U YES XNO WELL CASING DIA <br /> fF <br /> TRACTION 11 AIR HAMMERIDRIVEN CASING THICKNESS , $�6LI TYPE OF CASING p STEEL PVC p OTHER <br /> POR&W-1) MUD ROTARY DEPTH OF GROUT SEAL as' .$w-i TREMIE TYPE TO BE USED OAUGERS HOSE <br /> SPARGE6?-tj 0 PUSH POINT GROUT SEAL PUMPED ,dYes �No (NOTE MAXIMUM FREE-FALL DEPTH 15 30') <br /> a SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS Cc►-stn-{ �ro., <br /> p OTHER n OTHER APPROX BORING DEPTH i s' u,a [ OLTED TRAFFIC BOX or[]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? Al o -(if YES,list specifications here) <br /> "COMMENTS <br /> ' NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT 1V 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 �✓� Tdle/Compan /��� <br /> Print Namet. ,/ �1�w s�� _ Date ! 0 Z <br /> / DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: / l - Oil <br /> �` <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 /> MMENTS I CONDITIONS <br /> ACCOUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE4PERMIT I SERVICE REQUEST# INVOICE <br /> 3sca ► moi• a� 83 3 C-57 WC -WAIVER C-57Let#erof Authorizationto sin Encroachment doc 1/25/02 <br />