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W FILE COPY <br /> v <br /> J <br /> 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 /> Joaquin County for a permit to construct and/or install me work desuibed.This"application is made in compliance with San <br /> Application is Hereby made to Sari _ <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ' I1 Assessors <br /> WELL Location I -f(.Is S. —)+l,' S-t Cross Streett[ - Qty L'AtapZip Parcel# <br /> . JI-. 6115 Address �'JP� �/1 � C' /. Zip Utone# <br /> PROPER/ <br /> Owner r/(!//Ln[�p/N '/ ls1g [, <br /> C-57 Contractor r nY 1 M(ir�_Address NVI �I City�� Zip�az t LiclP�" tT Phone#t,767 —IOCV <br /> Consultant/Sub Cntr <br /> Address g3.7 Ski^—.� City�F " Lic# Phone# -7`/CO(- <br /> GIS Coordinates:X ,Y .Township Range Section <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> ',:SOIL BORING# 1]OVER-BORE. DIAMETER . <br /> WELL# p PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> a*Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING p HOLLOW STEM DIA.OF BOREHOLE�s[]MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: <br /> U EXTRACTION u AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: I]STEEL 0 PVC I]OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 2O K TREMIE TYPE TO BE USED: []AUGERS a HOSE <br /> Ja AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: u Yes Ao INgOATE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> A .�.XOIL BORING a HAND AUGER GROUT SPECIFICATIONS %Ki\ <br /> TO <br /> OTHER: {]OTHER APPROX.BORING DEPTH ALO Z O BOLTED TRAFFIC BOX 'of 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED N (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 I hereby certify t5at I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O n ces, RuleesWd ulations, and all applicable California State Laws. <br /> Title/Company e✓t—I' FO[• AG F— <br /> _6 <br /> - <br /> x /f' 1t <br /> Print Na ."c Z "19—O <br /> DEPARTMENT USE7ONLY sem. <br /> ' SITE MAP IN UNIT IV FILE,ADDRESS: 11%4 5- <br /> WORK PLAN DATED: /VD iJ 'aca <br /> Application Accepted By Dale Issued w. <br /> �...1,T" Area o6 <br /> _Grout Inspection By Date Final Inspection By a e <br /> Destruction Inspection By Dale <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DAT�E�/ PERMIT I SERVICE REQUEST# INVOICE <br /> I Q� ht_ 'P SR# 4Vto�� Z <br /> ' <br /> C-57_ WC -WAIVER C-57 Letter of Authorization to sign ermit Encroachment doc 9/30/02 <br /> n., . . g ... . .. <br /> .. .. sur <br />