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WELL PERMIT APPLICATION FORM SITE <br /> :�!;' I 'i'_ #i ,i_ {ItAI_1�1 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) MITIGATION <br /> 03 SEP -9 AN 8: dq4 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (209) 468-3449 <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 /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> '> ��j Assessors _ <br /> WELL Location SSI( S• .�l C�kWCL,{ 3S Cross Street 21•�-t R C. City V'C i's Zip 95STParceW 180 '03-1�- <br /> PROP R Y C - p <br /> Owner 12W(1"1�(),(Y1 �efV,'fCAddress �b5C)�1l 7�G.�I6, I� City �-G O: Zip �{ (Phone#��2��o��JJ-b�JJ� <br /> C-57 Contractor Gnyo, Address 1)• G0ct�3 City Liic-1JT Zip T6! Lic# ii!UC7Phone#(S?�D)�;�-,ZOl q <br /> Consultant/Sub Cntr. e-U�\/01 c Cw ,i�TSI-gess�00 I VEILS 1� �(fJ City�lL(.�`4�1��U L c // Phone# Z`7�0 4 S-. SlS <br /> GIS Coordinates:X Y Township -� S Range CE Section 3'i <br /> WORK TO BE PERFORM D: <br /> ®NEW WELL KBORIN (CPT GEOPROB HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> Q SOIL BORTJG# - (�U OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: L I h v �,C 6LVcL i it i v11 C7 C <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLEMULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS N TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 1 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes I No (NOTE: ') <br /> �:'MAXIMUM FREE-FALL DEPTH IS 30 <br /> 1SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS a Ql- n b, I l(' q Dud <br /> n OTHER: 0 OTHER APPROX.BORING DEPTH FC,[1\-0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED—WO (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 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County dinances, ules and Regulations, and all applicable California State Laws. }- / <br /> Signed x Cc�e Title/Company 11gtrt P.2�,G eU�Y1`Q C Consul T'O m+s <br /> Print Name SU�c- H. S ko C'- Date 7 ab03 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE ADDRESS: <br /> WORK PLAN DATED: Stl U Ctlk-LJ& 4--L-3 <br /> Application Accepted By Aq� Date Issued 11111m Area <br /> Grout Inspection By Date /(v Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 0,2101 1 3�8� ct�lu p� SR# 6o3Sf6? <br /> C-57_ WC--WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />