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SAN J OAQUIN COUNTY <br /> SITE <br /> { EI�XWNMENTAL HEALTH DEPARTMEL MITIGATION <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br /> • c P (209)468-3449 •Fax:(209)468-3433- Web:www.co.san-joaquin.ca.us/chd <br /> UNIT IV <br /> q�!F p•R�` <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 /> 201 l p Assessors <br /> WELL Location --c Cross Street (=h ICity.s "-�� ,a.� Zip R�Z� Parcel#_ <br /> PROPERTY Owner S w f ;� "dress Z2®� �, ���,!,��o , CilyS��l-�.. 7jp 21L'$ Phone <br /> # 2_ ¢C^02 4 <br /> C-57 Contractor cc�--- Address 2�L,�' vJ', City (at�4- Zip` f�-Lic# 12 7_61 Phone 2-ot ° S �� I t Z <br /> Consultant/Sub Cntr S �n(w F <br /> AddressZ 12( til, ('1"2.� City C Phone 4 7? rr,n c) <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> []NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION(choose type below) <br /> a SOIL BORING# <br /> �WELL# a OVER-BORE-DIAMETER <br /> PRESSURE GROUT <br /> D*Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS i` •v� <br /> ''MONITORING `�FtOLLOW STEM DIA.OF BOREHOLE �t� MULTIPLE CASINGS?a YES fl NO WELL CASING DIA: <br /> EXTRACTION /0 AIR HAMMER/DRIVEN CASING THICKNESS�N TYPE OF CASING: E STEEL�VC 0 OTHER: <br /> E VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS a HOSE <br /> IJ AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: a Yes p No (NOTE: MAXI/MUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 1 -"T�- C 'i� "�c'4 ', <br /> D OTHER: fl OTHER APPROX.BORING DEPTH —3E)' 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR YASING PROPOSED? (if YES,list specifications here): ` <br /> *COMMENTS:_ do k&,4,4, <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 /> 1 hereby certify that I have pre ared this application and that the work will be done in accordance with San Joaquin <br /> Count Ordinances, Rules d egulations, and all applicable California State Laws. <br /> Signed x Tide/Company L- <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By LK� Date Issued 1 a 1�'A--//0 S` Area `% 7 <br /> Grout Inspection BDate1 c c b Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> l •0t $�� 3 f ` fib ` P 1 �1_�-1-1 SR# L)04Sly _ <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 />