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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COU TY MITIGATION <br /> ENVIRONMENTAL HEALTH DE ARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-344 Y <br /> NON-REFUNDABLE PERMIT EXPIRES 1 Y AR 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 C ounty Environmental Health Department. <br /> { i q Assessors <br /> WELL Location � 1rP 1^AGtA __Cross Street 1 City_ L f _Zip+Parcel# <br /> PROPER T �_jPhone# <br /> Owner_ Y� Address �. City Zip <br /> C-57 Contractor flV i(bgoWp- _Address <br /> Consultant/Sub Cntr <br /> . ")C Address 7 SV,-- CitySib�"—tic# �-7 Phone# i <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORINGPT,GEOPROBE,HYDROPUNCH,HAND-AUGER, THER`) p DESTRUCTION (choose type below) i <br /> SOIL BORING# I7 OVER-BORE. DIAMETER <br /> p ELL# p PRESSURE GROUT <br /> B'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATI 3NS <br /> MONITORING U HOLLOW STEM DIA,OF BOREHOL a M LTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: <br /> ©EXTRACTION I1 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL. d PVC I1 OTHER: <br /> p VAPOR []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: It AUGERS g HOSE <br /> AIR SPARGE/OZONE USH POINT(GP or CPT)GROUT SEAL PUMPED: Q Ye No NOT : MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING HAND AUGER GROUT SPECIFICATIONS <br /> ()OTHER: OTHER APPROX.BORING DEPTH CJ Q BOLTED"TRAFFIC BOX or �STOVE PIPE: <br /> CONDUCTOR CASING PROP SED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGR EMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that thework will be done in accordance with San,loaauin <br /> County nanc2s, Rules and Iatio ,and all applicable California S//tate Laws. <br /> Signed x Title/Com any l5l G <br /> Print Name Date-4--7 <br /> — <br /> oq <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: - <br /> WORK PLAN DATED: <br /> Application Accepted By ate Issued D Area► <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> 4 COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BN—DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> jj�c 1��gLh q <br /> 9/30/02 <br /> C-57_ WCC WAIVER_ C-57 Letter of Authorization t sign permit—Encroachment doc� <br /> 4, <br />