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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> T3 304 E. Weber, Third Floor, Stockton, CA., 95202 <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 /> // D'/¢,-c Y <br /> Cit L a 7-A✓1.0eZip Parcel#_ <br /> WELL Location NQ /4 K 2 v A d Cross SVe'e3 <br /> ���.! C'4✓f�wa <br /> PROPERTY ✓v St S n� <br /> w erC�.C'fl �n vGl�'v✓ Address6 O/ .S. F� uerocL City LOS/ GIeJ ip�/vo�7 Pho7n�e#•7��o L] �5f to 32-30 <br /> /-�f'`� <br /> C-57Cogtracto �1 Address P oI 3�- Citysea y i ¢L�c# Phone#1 ' <br /> -fog. e,r G�4,-Po»d LS'GSZ Phone#��/y) 267 -4"ifI <br /> Consultant/Sub Cntr F'S rJ W c j t Address�U 0u ro aAw�, City Lic#G <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WWELL BBORI NG/ ((C(CPT, <br /> BE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 OVER-BORE. DIAMETER_ <br /> UCTIO (choose type below) <br /> O <br /> WELL# 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> 0'Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE �o f' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 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 HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE 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 Ordin nces, Rules and Regulations, and all applicable California State Laws. <br /> Signed x <br /> D� Title/Company�rf K c'�J° /� vy C✓c p f /✓1` <br /> Print Name u+ <br /> T Or S0 i.�c— Date /j <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRE <br /> WORK PLAN DATED: <br /> Application Accepted By D to Issued Area <br /> Grout Inspection By to Fi I spection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D Y DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 8° �os <br /> ' (ZZ SR g <br /> C-57_ WC.--WAIVER— C-57 Letter of Authori at' n o sign permit_Encroachment doc_ 9/30/02 <br />