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WELL PERMIT APPLICATION FORM SITE" <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., @&W 29 �,1014VV <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 /> WELLLocation (o(o(o W. WC- er' /♦rrL Cross Street GeV-Jtrn City Siock` Wo Zip9 203 Parcel#-J31.370-62 <br /> PROPERTY *y00 <br /> Owner Kb Ac Address305 N. Et Oofado ir. City_Cd f�"L_11l � �Zipci S2.a2 Phone# <br /> C-57 Contractor K.SZ Addressa`1�-D N. EQS� S�" Cityzip°I57 f ic# �O23 ho a#s3v-lohk--2 117- <br /> '++c 255 <br /> Consultant/Sub Cntr F[i.t�l-t..TPrh Address L,6S (AyilkWASW.�City$ p — Phone#`(/b'g29-L//y3 %ZZ, <br /> GIS Coordinates:X Y — ,Township I tJ Range Co E Section / O <br /> WORK TO BE PERFORMED: <br /> 'ANEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> OOIL BORING# '7 So 11 IOof�%np, a S66U U O-f O'C 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: �� iij <br /> S22 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 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 SPARGE1 OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes )CNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> XIS OIL BORING a HAND AUGER GROUT SPECIFICATIONS Ce v%IAA+ be V1­I'0nrS-2 <br /> D OTHER:-----xOTHERd1(eCf PUSAPPROX.BORING DEPTH 5- t U' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED — (if YES,list specifications in comment section) <br /> COMMENTS: tl OC%L�qp rzilp ' (PAIDn <br /> NOTE: OFFSITE BORINGS REQUIRE A CESS AGREEMENT OR ENCROACH ENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or 'nanceGs, Rules and Regulations, and all applicable California State Laws. <br /> Signed x mac--� Title/Company Fai*h-tec4\ <br /> Print Name (zm C I./11z,r Date '?/-2b/03DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS' <br /> WORK PLAN DATED: <br /> Application Accepted By .tom' Date Issued V a� Area <br /> Grout Inspection By Date 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# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> OI , a 6 U D SR# 3 <br /> C-57_ WC WAIVER_ C-57 Letter of Autho zati o sign permit_Encroachment doc_ 9/30/02 <br />