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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> APR 2 6 2004 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> ,ES 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 /> WELL Location 1!C LIJG ` LAY !LCross Street Li AjtoL,,j City 2r��-! Zip r Parcel# <br /> PROPER _ ` <br /> Owner ) � C�(/fy Address C J <br /> � 2' City GSC lal� Zip � Phone# 7 p ��Z f� <br /> C-57 Contractor� 4((' //_(-SI TLL _Address OX1.J f(A�' ' �(� City 2�n4iZ Zip 5� Lic#� Phone# 2� 3 30vD <br /> Consultant/Sub CntrA ,al r-. Address S5-] S fku r-f 'P CitySkrLiPhone# ! QU <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW rLL/ BORING (�,GEOPROBE, HYDROPUNCH,HAND-AUGER.OTHER-) p DESTRUCTION (choose type below) <br /> SOIL BORING# o OVER-BORE. DIAMETER <br /> u WELL# - <br /> - 0 PRESSURE GROUT <br /> a`Other GROUT SPECIFICATIONS <br /> COMMENTS: — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING a HOLLOW STEM DIA.OF BOREHOLE Z <br /> Y/Q MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS A TYPE OF CASING: <br /> Q STEEL a PVC Q OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL7TAL TREMIE TYPE TO BE USED: 'AUGERS a HOSE <br /> U AIR SPARGE'OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes rQ No (NOT : MAXI UM FREE-FALL DEATH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS �k LAAh> T- A <br /> a OTHER: a OTHER APPROX.BORING DEPTH Al a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PRCPOSED �� [� (if YES,iist specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 43 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prep red this application and that the work will be done in accordance with San Joaquin <br /> County 7u:� <br /> d egulations, and all applicable California State Laws. �1 ,��,,/`!!,, ,n� �,g",,�,�•' /1 <br /> Signed x FTitle/Company i, / $[ /1OVm"�JPrint Name � - r SAL _Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: r/ <br /> Application Accepted By `" to Issued ` 1�o Area <br /> Grout Inspection By / e Fi al Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> NV7 <br /> AID# <br /> FAC# <br /> AMOUNT REMITTED CHECK# REC'D EiY, DAT PERMIT/SERVICE REQUEST# INVOICE <br /> SR# <br /> C-57 WC -WAIVER_ C-57 Letter of Autho 'zat to sign permit_Encroachment doc_ 9/30/02 <br />