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O� ugly i' <br /> SAN.jy OAQYJIN COUNTY �' I <br /> � G <br /> ENVIRONMENTAL HEALTH DEPARTMENT)WN`� <br /> r <br /> 304 East Weber Avenue, 3d Floor, Stockton",CA 93202-2 UNIT IV, <br /> ' (209)468-3449 •Fax:(209)468-3433• Web:www.co.san joaquin.ca. hd ZpU-3 <br /> NTy <br /> WELL PERMIT APPLICATION FORM SAN JCAO"IN r L <br /> A <br /> r� I� ENvIRONME�T <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS U LTl-t OF-PARTMENT <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the workldescribed. 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 // 'C <br /> ;., WELL Location S'1� GJ/1 [. Cross Street /l'`Gl_Cc1 C':ty7/" Zip 7.�C � Parcel# �i` �t 7 <br /> PROPERTY Owner ge_ L3 S& }� <br /> c ddress CityZip Phone# <br /> y.. -57Contrctor �~ - dress <br /> L/ rte., ci ty l <br /> zip 22suchone# <br /> Consultant f Sub Cntr �`)' CF�t �f} Address �1-��^ GU,1 4- Ci `7L� .!k Lic#`a-� t <br /> �._.,.,. h .� 2 2(23 Phone# <br /> GIS Coordinates:X Y Township I Range Section <br /> t WORK TO BE PERFORMED: �. <br /> 0 NEW WELL 1 BORING(CPT,GEOPROBE,H DROPUNCH,HAND-AUGER,OTHER") DESTRUCTION(choose type below) <br />:• 0 SOIL BORING# ER <br /> 0 WELL# " "PRESSURE GROUT T <br /> ' ! p'Other: / Grout pecilica ons:_ „�4 T ,!�6Ic5 I7'" I <br /> COMMENTS: I I <br /> ,i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> "ONITORING "'HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?0 YES tNO WELL CASING DIA: Z <br /> 0 EXTRACTION /D AIR HAMMER/DRIVEN CASING THICKNESS �N 40 TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> �1 <br /> P. <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 1 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Yes 0 No f(NOTA: M1MU M FREE-FALL DEPTH IS 30') <br /> 0 S01L BORING 0 HAND AUGER GROUT SPECIFICATIONS:-_ 7' <br /> 0 OTHER: OTHER APPROX.BORING DEPTH in BOLTED TRAFFIC BOX or 0 STOVE PIPE i <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: <br /> f� �l <br /> j NOTE: OFFSITE BORINGS REQUIRE ACCESS OR3ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or a s, Rules Ulation d all applicable California,State Laws. <br /> Signe Title/Company ' r Cr <br /> 1 I <br /> Print Name Date —_t> <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT-IV 1LE,ADDRESS: / oo. +C <br /> WORK PLAN DATED: elv_Application Accepted By Date ss d <br /> Area <br /> .IF <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction'Inspection By Date w <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# !O <br /> PE CODES FEE INFO AMOUNTT�R®®E',MITTED CHECK# REC'D BY DATE PERMITIS ERVICE REcQ�UEEST�# INVOICE <br /> d1i i�sv. ZjD �S SR# <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign'permit Encroachment dock <br /> EHD 29-02-001 II WELL PERMIT SITE <br /> 827/2003 <br /> I <br />