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SAN JOAQUIN COUNTY SITE <br /> ENV�TtONMENTAL HEALTH DEPARTME-m-- <br /> MITIGATION <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br /> Lfj F2r t <br /> o oaquin.ca.usl(209)468-3449 •Fax:(209)468-3433• Web:www.co.san ) _ r..Uit N,I <br /> rI1T <br /> IV <br /> !p <br /> WELL PERMIT APPLICATION FORM <br /> F� <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 applitN - c�with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health De iA !17 <br /> WELL Location"s''{` 1c, L c Cross Street SQ�aiN ck City j7i .J �v J Zip � i <br /> 'Parcel —IA's—O S— <br /> !} <br /> PROPERTYOwnerCtrrUe ,.fi "77 ,4c7-t6 Address fZ6, /.�1 �r¢r 1+��,t City`s ���r •til Zi 7G Phone#ZU`9 L iu51 7 <br /> C-57 Contractor'scz j f�u,�t Address_ �l?r ,� '£i.�1 ( •" GtyS;i L� p. l Zp h ZLk; 'c#212L4 Phone#Gt 7 "'r 2 <br /> Consultant/Sub CntrF, Address 5 3©I/4ctt(tkr S� <br /> -- 'Or4'tybo%-�As�'�Lic Phone#S'10 — <br /> GIS Coordinates:X Y Township Ran?11'" Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) f. BESTRUCTION(choose type below) , <br /> 0 SOIL BORING# 1 <br /> VER-BORE—DIAMETER $ <br /> LL#�r.�$ j�S 0 PRESSURE GRO T <br /> *Other. Grout Specifications: ea 'r-- <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SP I ONS <br /> MONITORING 0 HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?0 YES ,' TIO WELL CASING DIA: 2.. <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNES TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GRO TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUTS ED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT PE IF ATIONS: <br /> 0 OTHER: n OTHER AP NG DEPTH `?d 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CON U T CASING PROPOSED? (if YES,list specifications here): <br /> *COMMENTS: f f rG Wt r-,- F <br /> NOTE: OFFSITE 13O(PJN0I1SkEQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALF.THE UNIT IV INSPECT 4 ORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> i <br /> 1 here4y cert), "that 1 have prepared this pplication and that the work will be done in accordance with San Joaquin <br /> County Ordi nces,Rlles and <br /> Regula ons, and all applicable California State Laws. <br /> j <br /> Signed x�_. �� — Title/Company <br /> Print Name k') <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I FAY s CA ,, l a1L„ <br /> WORK PLAN DATED:_ +{ l b J p 5— <br /> Application Accepted By Date Issued 6141,0 S� Area ?-1 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIO : <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 5S o2-- ,6ia.vo '( c-& 6j 6 4le's ` SR# ` Z S`iqj <br /> C-57 / WC_-WAIVER_ C-57 Letter of Authorization to sign permit ,- Encroachment doc_ <br /> EHD 29-02-001 WELL.PERMIT SITE <br /> 8/27/2003 <br />