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• • FILE COPY <br /> WELL PERMIT APPLICATION FORM <br /> SAN JOAQUIN COUNTY SITE <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) MITIGATION <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <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 /> WELL Location01I -T-6 40 L& N Cross Street�(`1��'���FIIII City Assessors <br /> PROPERTY/1 <br /> ter--- ��Z�P Parcel# <br /> Owner I b o Address r . <br /> (r to City. 2iPPhone# <br /> C-57 Contractor Address2A2 Hu, <br /> k <br /> q City tL2 Zip l�Lic Phone# 2 13-fib <br /> Consultant/Sub Cn(r � ( 2O (,. <br /> Address E. N I I-�I_City Lic# /3y 5 <br /> ��T' PhonetrI 50 <br /> GIS Coordinates:X ,Y ,Township Range.9 Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/ BORING (CP G OPR HYD'RQPUNCH,HAND-AUGER, OTHER-) DESTRUCTION <br /> 0 SOIL BORING# 11 N JJ IJ <br /> (choose type be�w) <br /> 0 WELL# O VER-BORE. ETER /L/ <br /> 0.Other 0 PRESSUR ROU <br /> COMMENTS: f -� 7[ r GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE <br /> D MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC <br /> 11 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Z D OTHER: <br /> TREMIE TYPE TO BE USED: 9 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE_kPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS IVO - �qrr <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTHS <br /> 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section <br /> COMMENTS: li ) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify I have prep red this application and that the work will be done in accordance with San Joaquin <br /> County Ordin a �s an Regulations, and all applicable California tate Laws. <br /> Signedx Title/Company �C4xrcr cC(!GrS ,�//tlL <br /> Print Name (i- <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: ( int n (Md �k Pjae,.jtitJ <br /> WORK PLAN DATED: / <br /> Application Accepted By - Date Issued y Z(1163 Area Z <br /> Grout Inspection ByU Date Final Inspection By _ Date <br /> Destruction Inspection By Dale --- <br /> COMMENTS/CONDITIONS: /M r P <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> `� �' /69 vL �! 03 SR# 333 6, <br /> 'C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc� 9/30/02 <br />