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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., 95202 <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 Joaqui C¢¢unty Environmental Health Department. <br /> �1, NAZft_TOnXz STuCKTcn Zi q 2p Assessors <br /> WELL Location 375 A11ELTON Cross Street—k +AY City nncc-�Z�i�p Jr' Y/Parcel# �(�47.0-6 <br /> PROPERTY O W - hA'ZPl�OrGity `STDG K ron Zip�Phone# ZO 7 777) <br /> Owner RT b Address 775 , <br /> � NAZip q.%7 -icR/75/'3 Phone# �� /�0L^� AvC-57 Contractor � aD 1)1n0.Addres L+7 �L« 7I4Ci tyCnR➢ <br /> Consultant/Sub CntrA. G Address S37 SHAW" CityTot ic"Llea�Phone#�/QO1p <br /> GIS Coordinates:X ,Y ,Township ` Range Section <br /> — <br /> WORK TO BE PERFORMED: <br /> --'KNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# a OVER-BORE. DIAMETER— <br /> NW <br /> IAMETER <br /> NELL# lf] !. aPRESSURE GROUT <br /> ther GROUT SPECIFICATIONS— <br /> COMM,ENTS: <br /> PECIFICATIONSCOMMENTS: <br /> Sfs ADlro ED V W M f{ naV <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ri <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLES 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Z <br /> Sthef\j)4t <br /> II EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Yo TYPE OF CASING: 0 STEEL -AVC p OTHER: <br /> yyy. POR0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS p HOSE <br /> ,5 IR Sp, <br /> OZONE 0 PUSH POINT(GP orCPT)GROUT SEAL PUMPED: 0 Yes o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 OILBORING OHAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: fl OTHER APPROX.BORING DEPTH 9i S BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSEDo (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 Or 'njnces, RuI nd Re tions,and all applicable Californi tate Laws. <br /> Signed x Title/Company ' K.. i;�Z� <br /> Pr <br /> int Name / �V DaleDEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED - <br /> Application Accepted By Date Issued 5/3f D/ Area�7 ZAP <br /> Grout Inspection By Date S//140 Final Inspection By Date ,/ <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> SR# ao317ar8 <br /> C-57 WC---WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />