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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 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. L <br /> / 1 Assessors <br /> WELL Locationn�NQ Cross SVeelU r�rc'� City L afit�o� Zip Parcel#_ <br /> `rvSf���aS G✓L�Wa7 <br /> PROPERTY 1n� 6 a L f p lfoo�7 f' L 3�� 3 J 3 o <br /> pw er C��fl lfo r Address ( .S. Fr u G r o 0. City �S '� G!c Zi <br /> Phone# <br /> Y u< <t r Sa 6 2 0 3 0 � r <br /> C-57 Contracto o Address Cit cr. o Zip4�is#- Phone#� <br /> o 7 KC <br /> Consultant/SubCntr �'Sro Wilt Address�UQu roaBwac, City!441f-d Lic#GLr0S-G Phone# �S-io) 2G7 -`� `�`e/ <br /> GIs Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> 'gSOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 6" 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: []AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 0 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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> Count�Z* <br /> Ordules and Regulations, and all applicable California State Laws. <br /> Signed x <br /> Title/Company�r"c'/�..� /�� <br /> Print Name a T. Or 6 0�"�� Date lj�"*-� It -LO- ,3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: P) <br /> Application Accepted By Date Issued �`' Area <br /> Grout Inspection By Date Final Inspection By ate <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R 'D DATE PERMIT/SERVICcELREQUQEST# INVOICE <br /> 2, Cl •�� �� �Z z SR# T O <br /> C-57_. WC -WAIVER_ C-57 Letter of Autho za on sign permit_Encroachment doc_ 9/30/02 <br />