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SAN JOAQUIN COUNTY <br /> � <br /> SITE <br /> E NMENTAL HEALTH DEPARTMEIPi MITIGATION <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 UNIT IV <br /> (209)468-3449 •Fax: (209)468-3433• Web:www.co.san-joaquin.ca.us/ehd <br /> aL1 FpR� <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 /> `` r( _ Assessors`?�L <br /> WELL Location � 1 d Cross Street c��.ta(City 5} Zip Z�� Parcel <br /> # <br /> PROPERTY Owner�.� ISICkm, Address \B(D E c ct City Zipl — Phone &'�� <br /> C'�'7 <br /> C-57 Contractor ( s- ¢, Address �� _.1� �_City_1,L pq S 7 <br /> � - ^��Z pA 7 Lic# Phone#o a .-13$ <br /> Consultant/Sub Cntr Address City �- Lic#I C=i S(GS Phone#(,`-z <br /> GIS Coordinates: Y ( Z i .`12 ZTownship Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# f C P-1 'Fi ms 4-'�-h 0 OVER-BORE-DIAMETER <br /> WELL# 0 PRESSURE GROUT <br /> O*Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE " MULTIPLE CASINGS?0 YES ONO WELL CASING DIA: <br /> 0 EXTRACTION B Al S <br /> R HAMMER/DRIVEN CASING THICKNESS # TYPE OF CASING: 0 STEEL 0 PVC B OTHER: <br /> B VAPOR . B MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: B AUGERS 'HOSE �^ <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: es 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING B HAND AUGER GROUT SPECIFICATIONS:r,/_� <br /> 0 OTHER: 11 OTHER APPROX.BORING DEPTH — ?c>1 0 BOLTED TRAFFIC BOX or B STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> *COMMENTS: �, 1°1 C' PT fz ti y -.a1=4 '9o c� c-oy L.rc�i L Q3 " ,•� t�1 9—� _ <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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin T,4 <br /> County Ordinances, Rules an ulations, and all applicable California State Laws. <br /> Signedx Title/Company A co <br /> Print Name i_->--I Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued_ /2 Z O Area e <br /> Grout Inspection By I 411-1—A--lNel Da l 4c.)6 Final Inspection By Date <br /> Destruction Inspection By Date II 1 <br /> COMMENTS/CONDITIONS: � - .c L .�-./� J i--�-,� - zxs i <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> � oI - ��- lo& a oL SR# oogbs <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> EHD 29-02-001 WELL PERMIT SITE <br /> 8/27/2003 <br />