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03/25/2004 16: 29 2094671" ' AGE STOCKTON PAGE 02/04 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA,, 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE.PFBMIT 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. t <br /> // // I' t�, Assessors "1 <br /> WELL Location t5a �a Yd1�Cross Street( b (en L`?cL�C City ✓/1JS�1L�C5�'� Zip�5Parcel� <br /> PROPER ) _ / q.2 t y f � p 3_q <br /> Owner��(/Q.� (.,[SLS/ �/rn°'-�Alldress �:t�, `7 ��'�Cit Zi Phone# <br /> C-57 Contractor Gwti� Address 1 <br /> Consultant/Sub Cntr�(Ict Address ,S Aci,w k, City 0 l4h Uc# ___Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO_ <br /> BE PERFORMED: <br /> p NEW WELL/BORING (COPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> SOIL BORING# 1 0 OVER-BORE. DIAMETER <br /> 0 WELL# a PRESSURE GROUT <br /> a'Other GROUT SPECIFICATIONS A-(e_tMPP__ <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING HOLLOW STEM DIA.OF BCRI-HOL , 8 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> (1 EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS,_,_,&r1,w,_TYPE OF CASING: a STEEL 0 PVC Q OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_._ TREMIE TYPE TO BE USED: )AUGERS p HOSE <br /> U AIR SPARGEI OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: U Yes p No (NOT MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BCRING a HAND AUGER GROUT SPECIFICATIONS <br /> OTHER: D OTHER . APPROX.BORING DEPTH �� ❑BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED__ (if YES,iist specifications in comment section) <br /> COMMENTS: <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHNIrENT PERMITS. <br /> 4S WORKING HOURS NICTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County finances, Rules a Regulations,and ail applicable California State <br /> '�Laws. <br /> Signed x Title/Company—y�& <br /> Print Name Cj Date_ <br /> CEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By – Date Issued �� I _ Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection f3 D <br /> COMMENTS/CONDITIONS: L t .. _ U 4C i{{ Y 1 C)✓ <br /> ACCOUNTING ONLY: Albin FAC# 7 7 c rl <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2 SR* 1�) <br /> C-57 WC_-WATVER� C-57 Letter of Autho' o S_ n permit— Encrooc ment doc— 9/30/02 <br />