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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> 02 QPR-5 ' ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> DDsc,_S1F,�F2pE (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit L cons <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> construct and/or install the work described. This application is made in compliance with San <br /> WELL Location V0.rie-S' Sec. 0.40,6.eck work FC ass Street Assessor's <br /> PROPERTY Owner c i:1-.r Joa�U i n City �'� ru Zip�15 0 Parcel# <br /> _�� Lw�h,r 1So+` Address_Cao a1 <br /> C-57 Contractor City_1=QkA0KbQ �15337phone# <br /> r� D n t\_ n�n,•d T�i�:j�8dress �t 56 12. .,o Roo,ot —�-- <br /> City�},nfZZiPS-455J_Lic# (6 Phone#Ii,5-31_.�I _1da <br /> Consultant Sub Contractor U2S ('o coo tet; <br /> GIS Coordinates:X Y So.,+e 300 Cityr°r"rnt`Lc# Phone# (\lb_ 6`7R-apo <br /> Townships,Range Section <br /> WORK TO BE PERFORMED: ---�_ <br /> PEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,0 SOILBNAND-AUGER. <br /> 0 WELL# RING# 11 DESTRUCTION(choose type below) <br /> 'Other: 0 OVER-BORE F <br /> COMMENTS: Grout Specifications: 0 PRESSURE GROUT <br /> zA �er5 � <br /> TYPE OF WELL INSTALLATION•rypE CONSTRUCTION SPECIFICATIONS <br /> U MONITORING U HOLLOW STEM . � <br /> DIA.OF BOREHOLES._MULTIPLE CASINGS?U YES 00 WELL CASING DIA:_ � <br /> O EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS Sd,.'<o PVC,0 VAPOR U MUD ROTARY TYPE OF CASING: U STEEL @QVC p OTHER: <br /> DEPTH OF GROUT SEAL VL`C 5 TREMIE TYPE TO BE USED: <br /> U AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: Yes ']]AUGERS U HOSE �` <br /> 0 SOIL BORING U HAND AUGER 0 O'1Vo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> GROUT SPECIFICATIONS: .: SIE*y'C. Cta <br /> (�,OTHER:42G2omo.le - 0•tSTHER'i)� }' klar° F +nark <br /> i 2c-t P„SI. APPROX.BORING DEPTH 30 96OLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED <br /> 'COMMENTS: See- Q Q VieA (if YES,list specifications here): <br /> rll rdh ;\ <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 /> C <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin C <br /> County Ordina es, R es nd ulations, and all applicable California State Laws. <br /> nSigned x <br /> Title/Company_ PZrOFCT /11gj LErc/U,Cs - a <br /> Print Name pr.GH.q,�/� �/� D yl<�� A' <br /> DEPARTMENT USE ONLY Date_ o�� o i <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: rr <br /> Application Accepted By� 7� d2_ . <br /> Grout Inspection By _Date Date Issued Area CV4l/ ri <br /> _ <br /> Destruction Inspection By Final Inspection By <br /> 14 <br /> Date <br /> COMMENTS/CONDITIONS: o <br /> ACCOUNTING ONLY: AID# <br /> cert' <br /> PE CODES FEE INFO AMOUNTREMITTED CHECK# REC'OBY DATE PERMIT/SERVICE REQUEST# INVOICE i <br /> aq•01 F4- n- 1�q I?- z/,/- s/ <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to Sin ermit SR# 602_'7?&G <br /> 9 p Encroachment doc 1/25/02 <br />