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WELL PERMIT APPLICATION FORM,,, t li SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 9520 SEP 29 dM 10: 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 605 W. WeloeiC AyC Cross Street L(ntol e\ City 5+OC4±pn Zip 95203 Parcel# 137-Z66 -/(p <br /> PROPERTY <br /> Owner ShOCl I-0 t\ 2�> Address3D5 P,E71 Qoraa�c�.,ary 1120Si0rCl -or, zipq_5_ZOZPnone# 209-G37 -88// <br /> C-57 Contractor 1253' Addres$920 Al ECLSt S+fee't City'kjjMk1an Zip9577(bUc# 80a34one# 536-4AP-2429 <br /> Sink 055 <br /> Consultant/Sub Cnlr I:LLNI, TQ CA.. Address 1015 S UN 1yefsi1-bity rm m flit Phone#916-R29-N7Y 3 Y ZZ. <br /> GIS Coordinates:X ,Y ,Township I tJ Range GI_ Section 1 O <br /> WORK TO BE PERFORMED: <br /> `(NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") D DESTRUCTION (choose type below) <br /> OIL BORING# Sall 1006v--A 38-2 DOVER-BORE. DIAMETER <br /> WELL# D PRESSURE GROUT <br /> D*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE 2" D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes �4o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> /KSOIL BORING DHAND AUGER GROUT SPECIFICATIONS "MPVL� <br /> D OTHER: OTHER APPROX.BORING DEPTH S- 16 ' D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> In� CONDUCTOR CASING PROPOSED — (if YES,list specifications in comment section) <br /> COMMENTS: 50 ik LIOOrl1`3 -iW CZlLP fli Ove bJ� 50iI Sn vn 1) t S. �t'ft� 1u�4t�L $On ('-n+vI A�3.fi Ori <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company r^+^n/nrc¢ /X-e-+6.T <br /> Print Name t r roL Date 4 0'� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: [J <br /> Application Accepted By Date Issued L f� Area <br /> Grout Inspection By! <br /> y ate inal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID *zati <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK PERMIT/SERVICE REQUEST# INVOICE <br /> � g t '0 ►C-57WC=WAIVERC-57Letter oermit_Encroachment doc_ 9/30/02 <br />