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cor '! <br /> WELL PERMIT APPLICATION FORM <br /> 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 SI't 1 C- <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 /> Assessors <br /> WELL Location gOO6 5'7-101 S O✓! Cross Street . U✓� City STw ./C rkA Zip Parcel# <br /> PROPERTY Owner(*id,e Azo-40).,,r(—uw,,eAddress Ci 90 6) �y�i y 1 ROr City Sa±�✓��rrrt-r?. Zip S 826 Phone#--(1 b 9-9'f6G6- <br /> C-57 Contractor Yl11V- ✓r� L AddressjL gik - 3 Cit dL. [�c Zip S1 Lic#Phone#-3U�?'rZZ30 <br /> Consultant/Sub Cntr 4? ^Sqv� /hc Address Cityr.,,,C)Mt(j Lic# Phone# V6 ?63' <br /> Sade /9 3' <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> JZSOIL BORING# /0 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING []HOLLOW STEM DIA.OF BOREHOLE []MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL 0 PVC []OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS []HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> []OTHER: []OTHER APPROX.BORING DEPTH F i 0 BOLTED TRAFFIC BOX or []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 have prepared thi ppli , ion and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regu ons all applicable California State Laws. <br /> �^ Title/Company //1/ <br /> Signed x �� <br /> Print Name DQ w1 S 0 ) Date_/D Y <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: � � w � <br /> WORK PLAN DATED: 77---3 <br /> Application Accepted By Date Issued Z� �3 `Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> GuC� <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 /> p 1a:V0 ��. 117/l sR# 6e�3� b(� <br /> C-57 WC V-WAIVER C-57 Letter of Authorization to sign permit ncroachment doc_ 9/30/02 <br /> 0 c-5 7 <br />