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Q <br /> WELL PERMIT APPLICATION FORM SITE <br /> 9 ,,jM0 AENjm HEALITI SAN JOAQUIN COUNTY MITIGATION <br /> . n[7�:li� r ��' ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 03 DEC 15 P>i 4: 0§04 E Weber, Third Floor, Stockton, CA , 95202 <br /> (209) 468-3449 ` �,—r O <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED iJ� l <br /> on is made m compliance with San <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described This applicate <br /> Joaquin County Development Title, Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> Assessors <br /> WELL Locatiora l� Cross Street SrCity 5"7'VCgnjj Z+p cj52,,06 Parcel# <br /> PROPERTY <br /> OwnerC /U a<r a,r AddressCity Zipg51?� Phone#_jL ?5('360 <br /> C-57 Contractor Address O L City kv w ile Z1pq g66Licft7 Phone#530 gg z230 <br /> Consultant 1 Sub Cnlr A H Address 'f Ad Sa Crry ��GLrc# Phone#_C16 rfaj 216 <br /> su�r� 1b <br /> GIS Coordinates X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> XNEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> jKSOiL BORING# OVER-BORE DIAMETER <br /> 0� 6 li []PRESSURE GROUT <br /> a WELL# / / W GROUT SPECIFICATIONS <br /> COMMENTS 3 <br /> rrR 2� . <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUC'T'ION SPECIFICATIONS <br /> aMONITORING 0HOLLOW STEM DIA OF BOREHOLE HOLLOW MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA <br /> EXTRACTION [I AIR HAMMER]DRIVEN CASING THICKNESS TYPE OF CASING 0 STEEL p PVC p OTHER <br /> VAPOR 0 THUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 0 AUGERS p HOSE <br /> 0 AIR SPARGE/OZONE `RPUSH POINT(GP or CPT)GROUT SEAL PUMPED 0 Yes p No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> $SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Near" Gs rn rMrdUA .0& b ertid»rre' _ <br /> 0 OTHER 0 OTHER APPROX BORING DEPTH 45 FY —a a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED Af6 _(if YES,list specifications to 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 have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordinances, Rules and flpgulations, and al[ applicable California State Laws <br /> Signed Tile/Company H G r!tr ups c✓" <br /> Print Name e G Date Z j l ZOO 3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS w �r <br /> WORK PLAN DATED: L3 OZ <br /> APP P Y <br /> Application Accepted B Date Issued 2 Z r Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction inspection By Date <br /> COMMENTS/CONDITIONS <br /> ACCOUNTING ONLY AID# FAC# <br /> EZ, <br /> S FEE WFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3 <br /> 1010 11• �j SR# Od tG� <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/30102 <br />