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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 />SITE <br />MITIGATION <br />UNIT IV <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 />e' i h. Assessors <br />WELL Location 511 St ;.t th �I)!lRO rti Cross Street 12-St�'�c {City Zip 9.�� 06 Parcel# ici 12- Oc s % <br />PROPERTY Owner ! kc ( .lt✓u,✓c_tti S��• Address PO I&C / 5-30 City S Zip r :S i 1 $ Pyhone# (3 I/t) ZS`i <br />/�.:��fiH`.Z �5/iY0/ iGa.,..rr 11ndYt.w) <br />C-57 Contractor ti?.'e-; t, 1 n 5. Tu Address 1150 City Zip���SS S Lic# Phone# (! z5) '3� 3 S 00` Vrn c -s -oq <br />Consultant / Sub Cntr nAddress Zit e-L�-t Sr--dhi:•tEC CityLic# Phone#(Er3)Z�, 1- 1547 <br />GIS Coordinates: X , Y , Township 1 Jy Range G. /- Section—2- L <br />VN'ORK TO BE PERFORMED: _ <br />ANEW WELL / BORING (CPT,)GEOPROBE, HYDROFUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 7 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0.Other GROUT SPECIFICATIONS <br />COMMENTS: t `. , t C:. P T <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ` - <br />$I ONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 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 (((\ /A\ <br />0 AIR SPARGE/ OZONE PUSH POINT (GP or C� GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') v '1 <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER:_G OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: _ '..E.., C. _ [ v//cc tr�� tf�, c _ <_ is. !_, F. 0 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. �1 <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 Regulations, and all applicable California State Laws. <br />Sigred •• `-` �✓I ljrt/�l <br />%''� ,.�. w11./ <br />n`. �.;: ^lr.a^,� ��). <br />7 Ln ✓, �:.. t t+ksa �� (/ l/.%iLC. �.. , 1-;' <br />Print Name <br />REC'D BY <br />DATE PE VICE RE # INVOICE <br />Date_ <br />89.00 <br />89.00 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />Z45'1 S o v+• ki r Ipo r t <br />WORK PLAN DATED:0,2 <br />0 0 4 <br />Application Accepted By <br />1 r y L <br />G <br />cr V lyE Date Issued J <br />rl e- 2 0 Area <br />Grout Inspection By <br />Date 11-23 Final Inspection By <br />y-2�0 <br />i/! Date <br />Destruction Inspection By <br />D to <br />COMMENTS/ CONDITIONS: <br />Advancemei+ <br />o-� rl GPT bOr;no1S - 13-1 <br />B-ZV-BT(� B-7 <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PE VICE RE # INVOICE <br />35-01 <br />89.00 <br />89.00 <br />413 <br />r SR# 00,38 Z <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit ent doc 9/30/02 <br />