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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />Fn r -npv <br />SIan on I <br />TE <br />MITIGATION <br />UNIT IV <br />OGS t✓D� <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 athe Standards of San Joaquin County Environmental Health Department. <br />_ Assessors <br />WELL Location 4 S1, /Ml Cross Street F• I berT 5r. City STpckl� Zip 9 d 05 Parcel# I'll '�2�10-oL2 <br />PROPERTY Owner 5 ro c k1 -'0A AddressW 5 N. El PV-gdo vl r City .SrD-'k-Zip Zp 9�2M Phone# ` f37- % 33 <br />C-57ContractorL/'�Q -TYISItLk Address GS'0 �OW'e %LA / City.�,,Yy,2Zip# G56'/b7Phone#I42S-313-6900 <br />VIj <br />Consultant / Sub Cntr(^4yAbr i 4 Env , Address a70 �eY�+NS c7 r. City O� OVLI Lic# Phone# %07- 2 33 -23, <br />GIS Coordinates: <br />N <br />Range <br />Section <br />WORK TO BE PERFORMED: <br />[] NEW WELL / BORING CPT)GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) [] DESTRUCTION (choose type below) <br />KSOIL BORING # .52-17 68- IB [] OVER -BORE. DIAMETER <br />[] WELL # [] PRESSURE GROUT <br />[] "Other GROUT SPECIFICATIONS <br />COMMENTS:-X13� Gv'e 10 ca —in Y -t -l2 51 clo-A)al k , N, Side s -F AV44AM7 ST C". 017 "e$ -7y <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />[] MONITORING [] HOLLOW STEM DIA. OF BOREHOLE a., [] MULTIPLE CASINGS [] MULTI-LEVEL WELL CASING DIA: N <br />[] EXTRACTION [] AIR HAMMER/DRIVEN CASING THICKNESS IV,4 TYPE OF CASING: [] STEEL [] PVC [] OTHER: <br />[] VAPOR (] MUD ROTARY DEPTH OF GROUT SEAL IDC) r TREMIE TYPE TO BE USED: [] AU& 9Mo H <br />[] AIR SPARGE/ OZONE PUSH POINT (GP or CPT) GROUT SEAL PUMPED: )tYes [] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING [] HAND AUGER GROUT SPECIFICATIONS dA4A &A1-QYD11t r <br />(] OTHER: [] OTHER APPROX. BORING DEPTH 100 [] BOLTED TRAFFIC BOX or [] STOVE PIPE <br />CONDUCTOR CASING PROPOSED—V b (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 Ordinanc , les egulations, and all applicable California State Laws. 1 <br />Signed x /%'17 � Title/Company (IA Y- QQ <br />Print <br />Y9 <br />SITE MAP IN UNIT IV FILE, ADDRESS: c;2 - <br />WORK PLAN DATED: 6-5-02-, <br />Application Accepted <br />Grout Inspection <br />DEPARTMENT USE ONLY <br />(�-ZO-0-t- <br />_Date Issued It— & 0 Z-- Area <br />nal Inspection By Date / <br />Destruction Inspection By - Date�-- — <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT/ SERVICE REQUEST # <br />INVOICE <br />� <br />�� �7 SR# ODr3 �/O <br />C-57-[ WC v` -WAIVER C-57 Letter of Authorizat!onjo sign permit Y "Encroachment doc ✓ 9/30/02 <br />