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WELL PERMIT APPLICATION FORM! SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) Cuff <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> 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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> -7 <br /> WELL Location /Z 1 E C h2U 4{Y Cross Street Sic'►11 S la u-, S6(k[n&j Zip.q�-Z11lz_.Parcel* 1,47--?4 <br /> PROPERTY�/ //�� l L,'{jA) Zi 9f,70(, <br /> Owner /��� 5 V V 4ii Address 7 Z 1 • C�Gr1c i� .Ur City S{OI pPhone# <br /> k'EGi�ci/.(�lJ <br /> C-57 Contractor 0511a66 ri <br /> .f Address 3632 Ojwe��C"ity_, �L, C, ZiPLic# l7S/!) Phone 7�i ��'- <br /> p <br /> Consultant/Sub Cntr / O� Address 4S 7 5A&w&1&i` City— 41 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL!BORING (CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# o OVER-BORE. DIAMETER <br /> 'WELL# t)" 1'V11N [I PRESSURE GROUT <br /> a'Other <br /> GROUT SPECIFICATIONS <br /> COMMENTS, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE ��a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: v? <br /> a EXTRACTION Q AIR HAMMERJDRIVEN CASING THICKNESSSP 1 Cf L TYPE OF CASING: O STEEL ;PVC G OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 'y 2&" TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE/CZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes a*No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS /SDI <br /> a OTHER:_-9 OTHER APPROX.BORING DEPTH_ r �I(BOLTED TRAFFIC BC or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED 11Je) (if YES,list specifications in comment secticn) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 45 WORKING HOURS NOTICE REQUIRED FOR 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. 7 <br /> Signed x !� �yX .1/L Title/Company �L <br /> �/ / �/"� J��t /J <br /> Print Name //(,7h/ !�i� / k,L���� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: -el <br /> WORK PLAN DATED: ?G �UCti ZDU� <br /> Application Accepted By LG <br /> ,eKo�i�/fOr\ —Date Issued DA{ Area <br /> Date Final Inspection By Date <br /> Grout Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> k <br /> TING ONLY: AID# FAC#S FEEINFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE Mw X89 3032- CWK 3 $ ay SR# CC 3 715 9 <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc 9/30/02 <br />