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urN � <br /> r >o coGy SAN JOAQUIN COUNTY A SITE <br /> y El= , iRONMENTAL HEALTH DEPARTi� sNT MITIGATION <br /> 304 East Weber Avenue, 3 a Floor, Stockton, CA 95202-2708 UNIT IV <br /> (209) 468-3449 • Fax: (209) 468-3433 • Web: www.co.san-joaquin.ca.us/ehd <br /> WELL PERMIT APPLICATION FORM <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 appltn an�d�Ap)r'ompliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Departure I "II ""11 <br /> n sessors <br /> WELLLocation .208'S f"LECMoN> ST Cross Street 440AE (- City S7oc-KTro /j �n � hfFEN {W��24/kbRLxr1 // Z 03 <br /> P <br /> PROPERTY Owner Te-- "e / fer'oih"✓o Address138� /+tY6AShMR4NCCity Sloc971� Zip7Sx�7Pho'fi <br /> C-57 Contractor /.a4=rb & 4- Address P , d . L oX 33 City e b V rS^rA Zip ggS7/ Lic# 7/o 079 Phone# 707 J75/ 3:0 <br /> Consultant / Sub Ontr A7G A-Ssber A- %ES Address ///76rN/41 PALrt 4L< Cityj6(o)!C-t'T4 Lic# Phone# C79 tzar <br /> GIS Coordinates: X Y , Township Range Section <br /> WORK TO BE PERFORMED: <br /> D NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) {TDEST UCTION (choose type below) <br /> aSOILBORING # OVER-BORE — DIAMETER IZr <br /> D WELL # M G✓ — � D PRESSURE GROUT <br /> p*Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING [] HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? DYES D NO WELL ASING DIA:_ <br /> D EXTRACTION D AIR HAMMERORIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEA TREMIE TYPE TO BE USED: AUGERS D HOSE <br /> D AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE- LL DEPTH IS 30') <br /> D SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: <br /> D OTHER: D OTHER APPROX, BORING DEPTH D BOLTED TRAFFIC BO r STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? ( if YES, list specificatio re): <br /> *COMMENTS: NCAT CEME1 /07 C i2c� u qJ <br /> O <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS OR ENCROAC NT RMITS. <br /> ul <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR AL REQUI IE <br /> NS, <br /> I hereby certify that I have prepared this application and that the work will be done o nceoaq in <br /> County Ordinances, Rules a ulations, and all applicable California State La s <br /> Signed N`� Tide/Company l� C—oc r G SES <br /> Print Name / ii�� r� Dal. V KZ ten <br /> I F77 <br /> DEPARTMENT US ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : Ao $ S qu vo o uA S <br /> WORK PLAN DATED : 3 3 S o -t 47z o <br /> Application Accepted By D to Issued1I r� _Area 2 <br /> 45) <br /> Grout Inspection By (A.�4 . C ej Date O Final Ins ction By 1� �'" Date <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNTREMITTED CHECK # RECD BY DATE PERMIT ( SERVIC ,REQUEST # INVOICE <br /> 3SOZ 4 ,6orrlo SIR# <br /> C-57_ WC.-WAIVER. C757 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EHD 29-02-001 WELL PERMIT SITE <br /> 8/272003 <br />