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SAN J OAQUIN COUNTY SITE <br /> ENV . NMENTAL HEALTH DEPARTMEO MITIGATION <br /> 304 East Weber Avenue, 3"Floor, Stockton, CA 95202-2708 <br /> • c P (209)468-3449 -Fax:(209)468-3433• Web:www.co.san-joaquin.ca.u.S/ehd UNIT IV <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 Titl�,Chapter 9-1115.3 and the Standards of San Joaquin unty Environmental Health Department <br /> �\� -a�-'�1 T 1`- N-*-...Tk- b As <br /> WELL Location_ tv a.c � S Cross Street C4 fi..ct City k"- ,Zip Parcel# <br /> PROPERTY Owner' R't c �- �j,� ,\Address'? Za ' I <br /> ((�'' PP � .>J t,y0.sl�:. i�CitySlI��-�-. Zips S�='S Phone# ��I ��`G� 826 <br /> C-57 ContractorlN�-dyJl � II 1 Address ? CitvT,o �5f� Zipf4s tJc#�I'tZ6tPhone a7 - 3az, <br /> WAI , <br /> Consultant/Sub Cntr�. s Address 2 l7 t C�Ik: �%q City�_R e-� Lic# Phone# Q z S ale I Lam <br /> 5 < U <br /> GIS Coordinates:X_`5�c.l�„.S1 Y 12 j 2 L Z?,S! ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) a DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE-DIAMETER <br /> WELL# (c� E PRESSURE GROUT <br /> O*Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> "fl MONITORING �ff HOLLOW STEM DIA.OF BOREHOLE �t' MULTIPLE CASINGS?a YES 0 NO WELL CASING DIA: <br /> E EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS SC tf 4c> TWE OF CASING: 0 STEEL K PVC 0 OTHER: <br /> [I VAPOR . o MUD ROTARY DEPTH OF GROUT SF_AL q]� ti TREMIE TYPE TO BE USED: GAUGERS E HOSE <br /> 1]AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> a SOIL BORING M7 HAND AUGER GROUT SPECIFICATIONS: k_ ( <br /> a OTHER: n OTHER APPROX.BORING DEPTH 3 b' Q BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> *COMMENTS: � <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 prepared this application and that the work will be done in accordance with San Joaquin <br /> Count' Ordinances, Rule d Regulations, and all applicable California State Laws. <br /> Signed x Title/Company 41 C_.0 Ci <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> 1' '��2D��- Date Issued f 1 0i <br /> 2-d D Area g <br /> Grout Inspection By !J t� Date 1 l (_6 Final Inspection By Date L <br /> Destruction Inspection By Date I <br /> COMMENTS/CONDITIONS: �c <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY] DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 9 �1 gl� ` 29` Qt, <br /> C-57 WC_-WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> FHD 29-02-001 <br /> WELL PERMIT SITE <br /> 8/27/2003 <br />