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SAN J OAQUIN COUNTY SITE <br /> { ENV NMENTAL HEALTH DEPARTME* MITIGATION <br /> 304 East Weber Avenue, 3`d Floor, Stockton,CA 95202-2708 <br /> • o P (209)468-3449 •Fax:(209)468-3433• Web: www.co.sanjoaquin.ca.u­s/ehd UNIT IV <br /> SLI F pR�` <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 D&velopment Title,Chapt r 9-1 15.3 an the Standards pf San*aquin County Environmental Health Department. <br /> g-fi r <br /> AssessorsWELL Locationity Zip�Pcel#s see2 t <br /> b�— <br /> ?� F v� S + 11 <br /> PROPERTY Owner �� �'''Address?"Le t '-c"ity <>d I-w.Zip`Icz�'3Phone# 2 WA q L <br /> C-57 Con tractOrA ,-d� Address 2i1- kJ,., k / City L Zjp`l"1�Vc# -05121 phone# 5 l� -6SL 767b <br /> Consultant/Sub Cntr ��S Address Z 12 I C-�1141—x"C'City Wu Lic#( �16 f Phone# �(z� <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,KNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) E DESTRUCTION(choose type below) <br /> SOIL BORING# 0 OVER-BORE-DIAMETER <br /> 0 WELL# <br /> a PRESSURE GROUT <br /> 0`0ther: Grout Specifications: <br /> COMMENTS: <br /> ",� <br /> TYPE OF YW£CL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS / <br /> 'MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_Z_A�L MULTIPLE CASINGS? YES Q NO WELL CASING DIA:Z <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNES,16c�4,D TYPE OF CASING: 0 STEEL jyPVC 0 OTHER: r' <br /> VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AU ERSJQSE <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: U Yes B No (NOTE: MAXIMUM FREE` -FALL D-EPqHIS 30') <br /> SOIL BORING U HAND AUGER ( GROUT SPECIFICATIONS: <br /> OTHER: n OTHER�•,c c c APPROX.BORING DEPTH^ Q BOLTED TRAFFIC BOX or a STOVE PIPE J <br /> CONDUCTOR CASING PROPOSED? <br /> (if YES,list specifications here): <br /> 'COMMENTS: a 1 e -c_e -4 � <br /> �r <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. 2 <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> Cou Ordinances, Rule Regulations, and all applicable California State Laws. I S <br /> Signed x Title/Company �� e�����'C L y-S — �a <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: c <br /> Application Accepted By Date Issued �i� �)�� Area 4 7 '*- <br /> Grout Inspection By 1-C-0 Dater I C-6 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 /> �.`I •�,I Fri ' +,�� <br /> SR# U <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> EHD 29-02-001 <br /> WELL PERMIT SITE <br /> 8/27/2003 <br />