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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 />SITE <br />MITIGATION <br />L_ <br /> <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APR 2 2 2003 <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 Departrr4OV I R UNI'Vl LNI HEALTH <br />WELL Location 3 3 00 Wa fico P-1- w-1-"f3' Cross Street ilefre94 aV-eCity ...44-e-f-191-,, Zip p 41D;L\ittirIERVICES <br />, 1. J /,?" , A , <br />PROPERTY Owner X.Ve It h b. k.'4. CY! lirdliress / 7E" C A, 81D ei- Will/ City NI I 0, fr" d Zip t4 Phone# <br />C-57 Contractor 1:142441--60-- 6,,,tr. Address PO hewc,131(1 City611.44141,4ip q‘.66-2-Lic# 73 4hone#116 910-0333 <br />Consultant/Sub Cntr00 ,0 v/OS en v Address J2 g 6--Jv 2-5... City621.etiliPtic# 6617 Phone# 9/‘ ril ii 0333 <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') G DESTRUCTION (choose type below) <br />a SOIL BORING # a OVER-BORE. DIAMETER <br />a WELL # <br />I PRESSURE GROUT <br />U *Other <br />GROUT SPECIFICATIONS i' <br />COMMENTS: <br />..t.k.itsee' i•ie--teaMite <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />3 MONITORING a HOLLOW STEM DIA. OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />O EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL 0 PVC BOTHER: <br />g VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />O AIR SPARGE/ OZONE a PUSH POINT (GP or CPT) GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />u SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br />a OTHER: a OTHER APPROX. BORING DEPTH a BOLTED TRAFFIC BOX or a 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 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 />Signed x 141---v•-)C1/2"--1 Title/Company <br />Print Name Name #01 / H iC. et) <br />Date 4 —//.03 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />Application Accepted By <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection . Date g Sy <br />COMMENTS / CONDITIONS: /0 .Z.Uf <br />WORK PLAN DATED: <br />Date <br />Date Issued <br /> <br />Area 79-7 A <br /> <br />7061,0 .5 <br />AID# FAC# ACCOUNTING ONLY: ONLY: <br />AMOUNT REMITTED CHECK # <br />717/ <br />REC'D BY DATE <br />1//; 5-7( <br />PE <br />SR# ()( 73 <br />INVOICE <br />PE CODES FEE INFO <br />QUEST # <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit roachment do 9/30/02