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U i>V <br /> N Baa = SAN JOAQUIN COUNTY SITE <br /> z IRONMENTAL HEALTH DEPARTE [P TTIGkTION <br /> CIE NEW <br /> st Weber Avenue, 3rd Floor, Stockton, CA 95 -2 UNIT IV <br /> M <br /> (209)468-3449 •Fax (209)45$-3433• Web www co san-Joaquin ca uslebd <br /> C` JUN 17 2004 <br /> ENVIRONMENT HEALTH WELL PERMIT APPLICATION FORM orf- <br /> ENVIRONMENT <br /> PERMIT/SERVICE ON-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 Assessors <br /> WELL Location 191 CdliltT'Y Qty ffiul. -_ Cross Street IvhSS1on City Sf;QCktCxl - ZIPParcel#_1121MCW <br /> PROPERTY Owner Y Address 1810 E. FaZjdtCn City� 'C Zip 95205 Phoney �4 5-� <br /> C-57 Contractor�1CCCh131c3 1 11 Address -�- �X City �O Z*94571 Lic# 71M79 Phone# 707 374-43M <br /> Consultant I Sub Cntr Address 1'86 E_ ppmy!r- a _City GfD=D-rrl Lic# rj�.Phone# 530 ff&5� - <br /> GIS Coordinates X ,Y Township 1N Range 6E _Section 4 <br /> WORK TO BE PERFORMED <br /> EW WELL/BORING(CPT,GEOPROBE HYDROPUNCH HAND-AUGER OTHER") p DESTRUCTION(choose type below} <br /> 1]OVER-BOR E—DIAMETER <br /> I]SOIL BORING# <br /> WELL 1]PRESSURE GROUT <br /> Other - Grout Specifications <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> PFMONITORING $WOLLOW STEM DIA.OF BOREHOLE $ii MULTIPLE CASINGS?0 YES ANO WELL CASING DIA 2" <br /> [I EXTRACTION I]AIR HAMMERIDRIVEN CASING THICKNESS S h-,SIO TYPE OF CASING [I STEEL gPVC p OTHER <br /> I]VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 10.5' TREMIE TYPE TO BE USED 0 AUGERSiOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED []Yes 0 No (NOTE MAXIMUM FREE-FALL DEPTH IS 30 <br /> U SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Nea-C rmt with 5%bEnt criite <br /> j]OTHER 0 OTHER APPROX BORING DEPTH 18 U BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED rice (if YES,[1st specifications here) <br /> *COMMENTS <br /> MOTE: 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 by done in accordance with San Joaquin <br /> County Ordinances, le a d RecJulatlons, and all applicable California State Laws <br /> Signed x Tit4e/Company Pro t 1 t Wast= <br /> Print Name Date G <br /> DEPARTMENT USE ONL � � <br /> SITE MAP IN UNIT IV FILE,ADDRESS alff <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> Date Issued 6 '+ Area r <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS <br /> FACCOUNTINIG ONLY AID# FAC# <br /> E CODES FEE INFO AMOUNT REMITTED CHECK# RE 'D BY DATE PERMIT I SER�VIICE REQUEST# INVOICE <br /> 0 N1U� $� �' S ` to—! 0 SRO QV 3� <br /> C-57 WC -WAIVErR C-57 Letter of Authorization to sign permit Encroachment doc <br /> WELL PERMIT SITE <br /> EHD 29-02-001 <br /> 9/272043 <br />