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1 <br /> 4P '�o • SAN JOAQUIN COUNTY SITE <br /> 2 a ENVIRONMENTAL HEALTH DEPARTMENT MITIGATION <br /> 304 East Weber'Avenue,3d Floor,Stockton,CA 95202-2708 UNIT IV <br /> & (209)468-3449•Fax:(209)468-3433• Web:www.co.san-joaquin.ca.us/ehd <br /> H�/GORN <br /> WELL PERMIT APPLICATION FORM <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 /> WELL Location nD�G —7h-A'Ly Cross Street Chr��SMAIJ City SLC Zjp5( lb Parcel# •� - <br /> PROPERTY Owner �y11 �I- t�1`L{ Address C.J6�d CIj�SMA13 City IQly�Z1P"1S i16 Phone# 1. QCI <br /> PACIFIC- ST tlLT�or l ddress T¢ti-1 1350 £. BcAf�t@K ST• Cityla/rV'flt-A+1DZiP615776 Lic#76 <br /> fiVr Contractor d a'rl 6806 Phone# C53r+�b67- -7812 <br /> consultant Sub Cntr)Vl ACl1%1. E,I G I1•IC• Address 1 wmwvo sxklJF,flA++�citr�`.L_� # Phone# �1%, W%713 <br /> GIs Coordinates:X ,Y ,Township Range Section <br /> NCH,HAND-AUGER,OTHER-) 0 DESTRUCTION cDIAMETER_ <br /> low) <br /> OVER-BOREh WWWOGCOO <br /> 0 WELL# PRESSURE GROUT <br /> ';fl'Other: FloRt2oty to t.— ILII—LUNG Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2 r MULTIPLE CASINGS?BYES ONO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER: V1 <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Xes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') o <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> (OTHER: H�>7- D OTHER APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> oo CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. F <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 <br /> Tide/Company <br /> (1/1` <br /> Print Name <br /> 5-T F fl/CK-c'-7° Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ge ILA UP <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By �� wa nate`1�3�t7�U Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: N <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3101 �� ll bU D sR# 6 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 W ELL PERMIT SITE <br /> 8/27/2003 <br />