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SAN J OAQUIN COUNTY SITE <br /> EN�*NMENTAL HEALTH DEPARTMEO MITIGATION <br /> 304 East Weber Avenue, 3`d Floor, Stockton,CA 95202-27-091: UNIT IV <br /> (209)468-3449•Fax:(209)468-3433- Web:www.co.san-joaquin.ca.us/ehd <br /> <Fa ��P FEB ` LU!1t7 <br /> WELL PERMIT APPLICATION FORM <br /> F!WIHUMVIL VT HEALTH <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 Tie,Cha ter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department Cid _.1 tl t7 S <br /> f /� 1 Assess <br /> IS '\c/ . 5� t7M f ty l�cn,f� o zi a�l Parcel# t�J3 -15c� -�)d* <br /> WELL Location (-\I Cross Street `l;i <br /> PROPERTY Owner i�.�fi�.'.�s ti Address 13 0 City c' zap S :l v Phone# 16 1 -33 C 5 <br /> //1� S �/ �� �(�. ,:�ti ,r >Fl Ili%• i �,1 <br /> C-5T Contractor N t ,� J'IcJ '�I�. so,J�(�address I G ,!- � ) ty ��c Zip �S�`��Lic#(< ���c 7Phone# �6� 3�J -��v� <br /> Consultant/Sub CntrN ' ( f���^:��'� ssc'Address 1 C Nck"�;I rW`9Gtybc�+ Lic# Phone#,�D q -. 36 7-00/ <br /> GIS Coordinates:X ,Y ,Township ''T 1\) Range L Section <br /> WORK TO BE PERFORMED: <br /> )'NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) E DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 1]OVER-BORE-DIAMETER <br /> 'WWELL# ,y1 W-f M UJ -.> j V11 W p PRESSURE GROUT <br /> D*Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,MONITORING FOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?a YES a NO WELL CASING DIA: <br /> EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS Sc I '/G TYPE OF CASING: p STEEL ,kPVC p OTHER: <br /> VAPOR . p MUD ROTARY DEPTH OF GROUT SEAL 3 S 1:1 TREMIE TYPE TO BE USED: E AUGERS fTiOSE <br /> AIR SPARGE E PUSH POINT GROUT SEAL PUMPED:,fYes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS: 7ef FICO <br /> p OTHER: a OTHER APPROX.BORING DEPTH 0 f-F a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? /V O (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 /> I hereby certify that I have preAared this application and that the work will be done in accordance with San Joaquin <br /> Couny Ordina ces, Rules and Regulations,and all applicable California State Laws. <br /> / I / 1 <br /> Signed x- L — Title/ComPIC, f c it jc- /AUC / t:' "t:✓c�",�, �SSr✓C <br /> Print Name A n')t r /\c,'b 1,-J S r,-j _Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1�1,5- , - 9 • b <br /> WORK PLAN DATED: Oc�- 11 , Z-005— <br /> Application Accepted By� ^� ` Date Issued I Area�L�-- <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: Z7T-T - L. <br /> F <br /> UNTING ONLY: AID# FAC# <br /> DES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> .�� ! �Cl � 3 7 0 �• l �c SR# ��5�1 <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 />