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o?" ("''•co • SAN JOAQUIN COUNTY • SITE <br /> ?a ENVIRONMENTAL HEALTH DEPARTMENT MITIGATIO <br /> 304 East Weber'Avenue,3A Floor,Stockton,CA 95202-2708 UNIT IV <br /> wt <br /> (209)468-3449• Fax:(209)468-3433• Web:www.co.san-joaquin.ca.us/eh <br /> 9�IFORWELL 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 rn'lh San <br /> Assessors X138 -01-01 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department.Assessyo'a <br /> �� 2a city (UcJcT�CA Pzip l—1 VV 83`i S��t <br /> DOg,C— S'NHRP� 9fXOTCrossStreet r <br /> WELL Location 1� r (/ C �(R0Y Zip JZ3)phone# <br /> PROPERTY Owner "Z- �Aq9 Address �J� Rb�N ,`'7• CiM <br /> 35b MoNI rp"Wety � r'zip 79�c#��'� tone#` <br /> C-57 Contractor e6 northern GA Address I I_� _ mtg1Zic# Phone# 6 0 <br /> Mph t �CP <br /> Consultant/Sub�rrtr t 1t1""�' C k� I -_Address 1� (+9 (C •xl '1E}�A�Qty <br /> Range Section <br /> GIS Coordinates:X�--'Y—�—Township <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> EW ELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) 0 0 OVER-BORE-DIAMETER <br /> SOIL BORING# p PRESSURE GROUT <br /> ii 0 WELL# d V��-may Grout Specifications: <br /> �IKOther.S'o it- Gfl5 <br /> COMMENTS: <br /> TYPE OF WELL INSTALS CONSTRUCTION SPECIFICATIONS <br /> 0 YES,�G`IO <br /> DIA.OF BOREHOLE Z// MULTIPLE CASINGS? WELL CASING DIA:_ <br /> 0 MONITORING 0 HOLLOW STEM TYPE OF CASING: U STEELVC 0 OTHER: <br /> 0 EXTRACTION 0 AIR ROTA R/DRIVEN CASING THICKNESS <br /> ;ff1VAPOR 0 MUD ROTARY <br /> DEPTH OF GROUT SEAL �o t TREMIE TYPE TO BE USED: 0 AUGERS OF <br /> OSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes `X (NOTE: MAXIMUM FREE-FALL DEPTH IS 30 <br /> GROUT SPECIFICATIONS: GG�-f F-t /6yE'r1 rDT11 t SPS ' <br /> 0 SOIL BORING D HAND AUGER BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 'pKbTHER 21 Kic CI PtXNAPPROX.BORING DEPTH 6+ 0 0 <br /> 0 OTHER: v l do ' if YES,list specifications here): <br /> CONDUCTOR CASING PROPOSED. ( r �)� 2g <br /> -COMMENTS: O/�F <br /> ra �vSK '1- - 2si o(,ti.�cfic7' fill <br /> su>V <br /> N TE: OFFSI E BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS M ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and <br /> li at the work <br /> ill be done in Laws, accordance with San Joaquin <br /> County Ordinances, Rules and Regulations,and all app R�Laws. <br /> fir! �/T-+ Er—� <br /> Title/Company�• P <br /> Signed x t,-7/ <br /> -7� ��. <br /> � MY G Date <br /> Print Nam DEPARTMENT I IRF ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: $/2 „ 7 <br /> /� ,Q Date Issued Area-/ %_ <br /> Application Accepted By /�Yi'C M^' -- Date <br /> Q Date a D Final Inspection By <br /> Grout Inspection By / y Date <br /> Destruction Inspection By <br /> COMMENTS I CONDITIONS: M-O L.l.l - - <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 8 � 11L / o SR# 03'70 <br /> C-57_ WCWAIVER_. C-57 Letter of Authorization o sign permit_Encroachment doc_ <br /> WC_-WAIVER-- <br /> WELL PERMIT SITE <br /> EHD 29-02-001 <br /> 827/2003 <br />