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SAN JOAQU)rN COUNTY SITE <br /> IRONMENTAL HEALTH DEPARTMENT MITIGATION <br /> Stockton CA 95202-2T08 <br /> COVEMst Weber Avenue, 3rd Floor, UNIT IV <br /> - (209)468-3449 •Fax (209)468-3433• Web www co san-joaqum ca us/ehd <br /> JUN 1 7 2004 <br /> WELL PERMIT APPLICATION FORM <br /> El�IVIR NMENT HEALTH <br /> a lSE1 <br /> t EPERMIT EXPIRES ISSUED plication imn wth <br /> Application is hereby m04eunty for a permit costrut and/or the work described Thsap <br /> Joaquin County Development Title,Chapter 9-7115 3 and the Standards of San Joaquin County Environmental Health Department Assessors <br /> WELL Location 1876 g Y Club Bl-yd- _Cross Street ML-331 City -1t4&tm zip95203 Parcel# 123-191-01 <br /> PROPERTY Owner Vs• FarV aTdtez Address 1633 W. W=11n zt City OC Cr1 Zip_TZ-3L–Phone#209 941 219L <br /> C-57 Contractor Woodward Address P.O. EOx 336 City L0 Vista zip 9-1571 Lac# 17 003_Phone# 4-4 a <br /> ddress % City Lic# 51P5D] � � <br /> Consultant lSub Cn �iE_ r Gxrc � # _ <br /> GIS Coordinates X ,Y Township 1N Range 6E Section 4 <br /> WORK TO BE PERFORMED <br /> IEW WELL I BORING(CPT GEOPROBE,HYDROPU NCH,HAND-AUGER OTHER') DESTRUCTION(choose type below) <br /> SOIL BORING# a OVER-BORE–DIAMETER <br /> NIELL# La 4 PRESSURE GROUT <br /> SOIL <br /> Grout Specifications <br /> COMMENTS- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFI AT S <br /> `MONITORING �I IOLLOW STEM DIA OF BOREHOLE 8' ' 106LTIPLE CASINGS?p YES ,'KNO WELL CASING DIA 21' <br /> p EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING p STEEL R PVC p OTHER <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 10,5_ TREMIE TYPE TO BE USED 11 AUGERS HOSE <br /> AIR SPARGE p PUSH POINT GROUT SEAL PUMPED :0 Yes 0 No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING j]HAND AUGER GROUT SPECIFICATIONS Neat with 51%,bMt -it;e <br /> []OTHER g OTHER APPROX BORING DEPTH i Z9 ABOLTED TRAFFIC BOX or []STOVE PIPE <br /> �? A CONDUCTOR CASING PROPOSED m (if YES,list specifications here) <br /> 'COMMENTS ZZ Z7 f <br /> to:. 4�w S t tea` To ' <br /> NOTE OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <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 Ordinan s, Rules and Regulations, and all applicable California State Laws <br /> Title/Company Prt��Ct jcgi-st., Stern <br /> Signed x _ G <br /> Pnnt Name Date w p d' <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS' <br /> WORK PLAN DATED: Jp. <br /> / /��� _ Date Issued 6 <br /> Application Accepted By_--=' — <br /> "`'" <br /> Grout Inspection 8y <br /> Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS <br /> ACCOUNTING ONLY AID# FAC# <br /> E CODES FEE INFO AMOUNT REMITTED CHECK#I�,p REC'D BY DATE _ PERMIT'7 SERVICE REauEST# INVOICE <br /> A W J WJ 1 <br /> IN— <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment docN <br /> WELL PERMIT SITE <br /> EHD 29-02-001 <br /> 8127!2003 <br />