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WELL PERMIT APPLICATION FORM SITE <br /> �l SAN JOAQUIN COUNTY MITIGATION <br /> t ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> �D 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (/ (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FIE-M <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appligtion is made in compliance with San <br /> Joaquin County Defv�elnQnr� nnt�,�Ttia (hantarr q.,-1115.1 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location N/ 356D�7/�j/ L/ moss Street p Assessors <br /> - ity Zip /53 x, Parcel# ;o9-050-08 <br /> PROPERTY <br /> Owner_7i IM,919( C6himU.✓/-r/.£S LA dress, /XO T/t'RL'/ 3L, IISTD 4City�2S�Y Zip' ,Y3Z Phonnee#`o2�a7y- �3G-/S4o p <br /> C-57 Contractor U �L,y�x c Address " y /�� S City>1+Ce-"441 Zip,��i ic#TR y Phone4 <br /> Consultant/Sub Cntr Ty />C�AYJ 612eL. S ,ey�r /(o <br /> �ddres�`1Zc�!lvLL cwr2 Pr1wYc;tyl'Lk4sA.�7L,4L;c* Pnone#9zs-y2-6_�Goo <br /> GIS Coordinates:X ,Y I 41,E,Township S _Range <br /> Section <br /> (9 5 661 <br /> WORK TO BE PERFORMED <br /> XNEW W I: /BORINGCPT,GO�GEROBE,HYDROPUNCH, HAND-AUGER,OTHER') 1 ZDESTRUCTION (choose <br /> 'SOIL BORING# C-6 type below) <br /> 0 WELL# 0 OVERBORE. DIAMETER <br /> 0*Other gPRESSURE GROUT <br /> COMMENTS: S -Co RF G e-7;�o ROUT SPECIFICATIONS <br /> �4F j 6✓� qm/�L/.✓Yo <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE-L 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS YPE OF CASING: 0 STEEL 0 PVC .O OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 1po (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS — <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 30 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certi hat I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi an es, Rule a Re lation , and all applicable California State Laws. <br /> Signed x Title/Company e. 6,60L-06157-- CL,L3y%J-J 612e&,f/ <br /> Print Name -T)W9L x) 61 145y'T� Date__ 7-15 -ZGD <br /> DEPARTMENT USE ONLY L <br /> SITE MAP IN UNIT IV FILE, ADDRESS: f <br /> WORK PLAN DATED: <br /> Application Accepted Bysl-� Date Issued Area O(L/ <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: t <br /> 2 -D3 <br /> ACCOUNTING ONLY: AID# FAC# <br /> qC-57WC <br /> FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> � g�3- .p3 SR# <br /> -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/30/02 <br />