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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., 9520,2 JUL 20 <br /> (209) 468-3449 LUuUJ <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS84g8D J (i 1 if< C OUf:'I '�� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This Ik�If�hFi$(+y@flpjwr mpllance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin CountyEnvironmentalf e "A I;T E N T <br /> � � g p / / Assessors 20 <br /> _Z/ <br /> WELL Locationr�3a/5 S,rr'�N �,cIC Z Cross Street City Zip Parcel# OHO <br /> PROPE / J / <br /> owner Lt !1/,Z ^I' lC Addres5d�t)�S� ST7ca,rLer��C City/�Y ` Zip Phon�e�#�qy� <br /> C-57 Contractor r. ,1/��/;, �I Address,{;l) ��.5/ City.t5k 1.1 Zip WY/Lic#;;W Phone#r//G(o 7z��7J7-4/L�U ) <br /> Consultant/Sub Cntr e er�'U=(;<�{Q((/ Addres Xo���nu�2rlF City KAJ Lic# Phone# 21- �t/J --�3r <br /> GIS Coordinates:X ,Y .Township Range Section <br /> WORK TO BE PERFORMED: <br /> )KNEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) D DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> WELL# / , r +r- 3 i / 0 PRESSURE GROUT <br /> GROUT ROUT SPECIFICAATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> AMONITORING AHOLLOW STEM DIA.OF BOREHOLE, 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:a /� <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS O TYPE OF CASING: 0 STEEL XPVC a OTHER: <br /> O VAPOR o MUD ROTARY DEPTH OF GROUT SEAL /l7 TREMIE TYPE TO BE USED: XAUGERS 0 HOSE <br /> AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes ;"o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING O HAND AUGER GROUT SPECIFICATIONS ✓f/Q•,�cQ-M'k^?t7 <br /> OTHER:_0 OTHER APPROX.BORING DEPTHBOLTED TRAFFIC BOX of XSTOVE PIPE <br /> CONDUCTOR CASING PROPOSE (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 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, Rulez and Regulations, and all applicable California State Laws. <br /> Signedx Title/Company S, Sy ' &,W, <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> �. FILE COPY <br /> SITE MAP IN UNIT IV FILE, , RISS: � <br /> 01 30 3 T �� <br /> WORK PLAN DATED: -. ,r <br /> O S / Gr <br /> Application Accepted By CA-1 Date Issued Area <br /> Grout Inspection By Date g L O 5 Final Inspection By ( Date_ — Q <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> °` 2,512_ zS° Ck '} z-Qros SR# pU c,13 2-113 <br /> C-57_ WC=WAIVER_ C-57 Letter of *t4rization to sign permit_Encroachment doc_ 9/30/02 <br /> FILE COPY <br />