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'pPQU lµ•C0 •SAN JOAQUIN COUNTY SITE <br /> G <br /> ?` 2 ENVIRONMENTAI-HEALTH DEPARTMENT MITIGATIO <br /> y <br /> 304 East Weber'Avenue,3rd Floor,,Stockton,CA 95202-2708 UNIT IV <br /> \' (209)468-3449• Fax:(209)468-3433• Web:www.co.san-joaquin.ca.us/ehd <br /> crkbR WELL PERMIT APPLICATION FORM <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 /> r Assessors <br /> Joaquin County Development Tale,Chapterg-1115.3 1.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ,fyJ�L —sm F>LFPE Pmcross Street {'c°TN k7D City'60s-A `AW Zip�Drjj Parcel# 1�-d3-U�1(t . <br /> WELL Location rr t Oaf a'1P Zi `"Zjj Phone# �3� `J '� <br /> �L'A '� 4Wk) Address aJQ �� �jt�— p <br /> PROPERTY Owner tl q�(, '76�SC�Phone#(53ci)V 1-733)2— <br /> PRL F, JTIL-A S 13�y E.6f+aa"rsjCiryrusbYhs� Qp otic# <br /> C-&rContractor -isT�O LTtOrr Address � � (1 ?�n- � <br /> n cc fLCU'Lic# Phone#vl� J <br /> consultant ubCntrMAc-Te'- rG-AC' AddressI� 1`ocKtp6f\atvtciryJ�. <br /> Township Range Section <br /> GIS Coordinates:X •Y <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> �U1JEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 OVER-BORE-DIAMETER <br /> (� 0 SOIL BORING# PRESSURE GROUT <br /> 0 WELL#------ P LI K ILr CA • Grout Specifications: <br /> '�bther: {101 ^L 91r c?cON+r� <br /> COM ENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS CASING <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTrIPPE OF CASING: PEST E LOO PVCLLO OTHERDIA:__ <br /> 0 EXTRACTION 0 AIR HAMMERIORIVEN CASING THICKNESS TF EMIE CASINTYPE TO BE USED: 0 AUGERS HOSE <br /> 0 VAPOR MUD ROTARY DEPTH OF GROUT SEAL <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED:`J�es 0 No (NOSE MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> +Jif)THER: FA O OTHER APPROX.BORING DEPTH D <br /> CONDUCTOR CASING PROPOSED? (�ES�specifications here) Lam{ <br /> �tYsri o rPzcyY1� dlr�P�1i ffi <br /> *COMMENTS: <br /> is :::::, a <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regu ations,and all applicable California State Laws. <br /> . Q¢tT-ICl90'fL— �^IglriI-r� . <br /> Title/Company <br /> Signed x <br /> oe-r— Date <br /> Print Name DEPARTMENT USE ONLY <br /> ncwiA� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ^ �' <br /> WORK PLAN DATED: <br /> Date Issued 0 Area '7'7:2 <br /> - <br /> Application Accepted ByDale 3 Final Inspection ey Date <br /> Grout Inspection By <br /> Da <br /> Destruction Inspection By te <br /> ltiti5 <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY I DATE PERMITISERVICE REQUEST# INVOICE <br /> 9D/ C1- - Q (pU ff I SR-9 QO -S <br /> C-57_ WC—WAIVER_ C-57 Letter 0T Authorization to Sign permit_Encroachment doc_ <br /> W ELL PERMIT SITE <br /> EHD 29-02-001 <br /> 8/zv2003 <br />