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WELL PERMIT APPLICATION FORM SITE .IEAI TII <br /> SAN JOAQUIN COUNTY MITIGATION r r. <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) yy JLT 1 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 $Ei' 29 AH Int 43 <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 /> Assessors <br /> WELL Location 720 W eSi- W giber'•A'vC.Cross street LI�City Sto n Zip`I5w3 Parcel# 132-370-01 <br /> PROPERTYN4� <br /> g52o q-9N8 � $ZBs) <br /> Owner a�2 Addressq + + t�1 Q,1e2r ,4tlC City�J�O�Ic�ov� Zip hone#ZA <br /> CitD23Pi <br /> C-57 Contractor 915-r AddressZ20 N. =0.54 54Pt ( ge# 530-(ob&-a42t{ <br /> Consultant/Sub Cntr IFrLf-Ir'AA74? Q Addressl55Ll111tJatSl��A_1`CifX!Sjf R# _ Phone#RIb4Z9-t4/43rZZ <br /> GIS Coordinates:X � ,Y ,Township I N Range (D F Section <br /> WORK TO BE PERFORMED: <br /> �'I EW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> (" )C'SOIL BORING#SSolt <br /> lnM,ft�f OI SDiI JOLP Br DOVER-BORE. DIAMETER <br /> Jj WELL# U PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS:,j <br /> sat V0.p • Sv-lo Sy-asy-� SV-11 Sv-l2 SJ-l3,sV-ly sv-\5 Sv-!/o <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> U MONITORING 0 HOLLOW STEM DIA.OF BOREHOLES O MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN 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 /> ��,, Il 011AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30X ') <br /> SOIL BORING HAND AUGER GROUT SPECIFICATIONS cern Bt' } ben' p('09 <br /> 0 OTHER:_'WOTHERQt r V\ APPROX.BORING DEPTH c;'-(D ' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED � (if YES,list specifications in comment section) <br /> COMMENTS: i orin �� ll? On SAI.Q <br /> NOTE: OFFSITE AORINGS REQUIRE ACCESS AGREEMENT OR ENCROA HMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 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 Title/CompanV f Ea-[`hnTPP.G. <br /> Print Name Date 0 b 02 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted ByDate Issued (� Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R C'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57_ WC=WAIVER_ C-57 Letter of Author ction o sign permit_Encroachment doc_ 9/30/02 <br />