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SAN JOAQUIN COUNTY , FILt ug", <br /> .: <br /> ENVIRONMENTAL HEALTH DEPARTMENT MITIGATION <br /> 304 East Weber,Avenue, 3`d FIoor, Stockton', CA 45202-2708 <br /> (209)468-3 <br /> 449 •Fax:(209)468=3433- Web:www.co.san-jaaquin.ca.us/ehd ,, y <br /> WELL PERMIT APPLICATION FORM <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED OW410 <br /> ? Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is ma%Kw6e, <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 4ssc�lCl <br /> � WELL Location .1421 . CA 0WA't Cross Street �U�1Elr t.c icl City " -.r,•C�'�-.�C1` - >" � 7 � <br /> � Lip /'�, �,+ _ Par <br /> PROPERTY Own <br /> Z_If?// Z_xAddres6 Cty _Zip�Phone# <br /> C-57 Contractor .'-P, . Address �S� cJ/ L f!n ! City Zip'7_12W Lic#S1ZZ(�Phone# IL > 571"- <br /> g <br /> Consultant 1 Sub Cntr Address City ! Lic# Phone# <br />[=, GIS Coordinates:X Y Township 'd Range Section <br /> WORK TO BE PERFORMED: } <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) +I DESTRUCTION(choose type below) I <br /> '0 SOIL BORING# i!p ER fry <br /> O WELL# I �! PRESSURE GR <br /> 0*Other: [9i Grout Specifications: 7 <br /> COMMENTS: f <br /> a TYPE OF WELL INS TAC ON TYPE CONSTRUCTION SPECIFICATIONS <br /> -P,MONITORINGLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?(]YES KNO WELL CASING D : <br /> IA. <br /> EXTRACTION 1]AIR HAMMERIDRIVEN CASING THICKNESS FI U TYPE OF CASING: 0 STEEL jpVC 0 OTHER: <br /> I ' 0 VAPOR 11 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 'i 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: l es 0 No (NOTE: M IMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: 11 OTHER APPROX.BORING DEPTH i� p BOLTED TRAFFIC BOX or p STOVE PIPE + <br /> CONDUCTOR CASING PROPOSED? (4YES,list specifications here): <br /> *COMMENTS: <br /> l N + <br /> ' NOTE: OFFSITE BORINGS REQUIRE ACCESS OR,ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS:. p <br /> r.4 f <br /> I hereby certify that I have prepared this appli ation and that the work will be done in accordance with San Joaquin <br /> ra Coun in es, Ru ulati , and all applicable California S a Laws. <br /> Signe 'x Title/Company <br /> Print Name K Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 61/ N• S [J1 •3� <br /> WORK PLAN DATED: ar <br /> ✓K�'^•'� I <br /> Application Accepted By Date Issued F r mea 1 <br /> Grout Inspection By Date Final Inspection By Date i <br /> Destructionlnspection By Date <br /> 'COMMENTS I CONDITIONS:. <br /> i <br /> ACCOUNTING ONLY: AID# FAC# a <br /> PE CODES FEE INFO AMOUNT REMITTED- CHECK# REC'D BY DATE ii !PERMIT/SERVICE REQUEST# INVOICE <br /> 0 <br /> G•57 WC -WAIVER C757 Letter of Authorization to sign permit Encroachment docN <br /> EHD 29-02-001 WELL PERMIT SITE <br /> 5272003 6 <br /> ,4 ! <br />