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f <br /> WELL PERMIT APPLICATION FORM <br /> SAN JOAQUIN COUNTY VIC GATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) NIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA 952029 Ah I�' 4 <br /> (209) 468-3449 1 Cr L <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 /> ,1 nn ��_� Assessors <br /> WELL Location 50'I VJ.Wi°_��- ArVC- _Cross Street l Ar% City k n ZipQ�JZ¢)_3 Parcel# 137-37D 03 <br /> PROPERTY (J /� 0 <br /> Owner S+oCk4on R UA Address3D5 N. EI OOraolos�'Ci Iy CKa-en Zip`f 52-0ZPhone# Z q-`/37-8$) I <br /> 3y <br /> C-57 Contractor RSZ Address a30 N- EaS+ S+- city�A)Otdlump Zipj5"17*c# &02hone#S3U-bb$-2429 <br /> Consultant/Sub Cntr S2Xxkv.18 , Address G!55 UniVfAslk,�e�,�eci8155t0hnfAmNl+biC# Phone#q/16-929-q1437rZZ <br /> GIS Coordinates:X � ,Y ,Township I tJ Range 0 F Section (O <br /> WORK TO BE PERFORMED: <br /> 'gNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> OIL BORING# 59-2.o 0 OVER-BORE. DIAMETER <br /> is WELL# a PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLES a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes )(No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> A'SOIL BORING a HAND AUGER GROUT SPECIFICATIONS U m2y1'r bgnzF 2y\'2C. <br /> 0 OTHER: )(OTHERd.I tea 9yS APPROX.BORING DEPTH /Or 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS:16\ %006c 4-0f IQ S (Y Y on LO <br /> NOTE: OFFSITE BORINGS REQUIR ACCESS AGRE MENT OR ENCROAC MENT 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, Rules and Regulations,and all applicable California State Laws. <br /> Signed x r()A-(Q Title/Company &.Agf . �+�1'-fV�TPri� <br /> Print Name (ArM E K C2f Date 912h/n3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADORES <br /> WORK PLAN DATED: A <br /> 77 <br /> Application Accepted By •'- Date Issued d 40D —Area— <br /> Grout <br /> reaGrout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOU*ONLY: AID# FAC# <br /> PE CODAMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> gg ADO <br /> q130lig SR# 3 q_G <br /> C-57_ WC=WAIVER_ C-57 Letter of Author&t'o to sign permit_Encroachment doc_ 9/30/02 <br />