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EC,E� �n <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY NOV 0 7 20%ITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT .MENT HEM IT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., �IT/SERVI_GES <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I's nce with San <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 <br /> Environmental Health Department.nt Title Chapter 9-1195.3 and the Standards of San Joaquin County P <br /> Joaquin County Development p <br /> ,``�tVI Assessors <br /> � <br /> WELL Location `�t`A'S N Fe-rSV�'Y �� � .Cross Street � `"h_ate, City S Zip Parcel# <br /> , <br /> PROPERTY owner S i r S2�dlnw Address 255'11 Cre sk;,L # r. City 2� : V RP- ZipOA552-Phone# 510-'i1D-5100 ex <br /> C-57 Contractor_6YeACI ``W, 11 1Q Address DJ-50 fAOLO.1— 14. City l r, INt Zip� #�3 Lic "&-Phone# 72�`'J13'S�aD <br /> jj <br /> Consultant 1Sub Cntr1.mm6,1A-�y• Address 2-70 PPXk,VlS 5}• City S0"6MN Lic# Phone# loI-1)3S`i8G0 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL! BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) �R6ESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> a WELL# L2411RESSURE GROUT J <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING Q HOLLOW STEM DIA.OF BOREHOLE 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 BOTHER: <br /> L OAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> p AIR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE=FALL DEPTH IS 30') <br /> a 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 /> I hereby certify that I h e p epared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi u n d_R e ons, and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued ��/� Are rQ <br /> Grout Inspection By Date // Final Inspection By Date L 6Z <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: u/�Q <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 7_z,60 1117lo-t- SR# C)a-;j 833 <br /> C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment dot 9/30/02 <br /> 1 <br />