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U Q ORIGNAL <br /> WELL PERMIT APPLICATION FORM. SITE <br /> TION <br /> � <br /> SAN JOAQUIN COUNTY UNIT MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (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 to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessor's <br /> WELL Location PD Pb Rd 1+ _ Cross Street C-T City S-�OCKD n Zip ter'aO3 Parcel# <br /> PROPERTY Owner FoA,o� Q-k.-cCk,orl Address P_O.-_6Ox aC'69 CityS C -b0 Zip �=l Phone#-W 4-6-Oa" <br /> C-57 Contractor.5PgC+rUtn t"0.' ddress .2305 V0jq Mw0_m Dr City.$inck- n Zip 51d5Lic# Phone# 0q_4b5-�71a- <br /> '1 N <br /> Consultant!Sub Cntrjjeo MA-_tr I A (on5ul Address14W4, lZingf.S-6e-2J5 CitynC' no Lic#6803865 Phone# ��64 x-535 <br /> GIS Coordinates:X Y Township 11y Range 6 [— Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL!BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> []SOIL BORING# []OVER-BORE <br /> 'WELL# 3 -b 5 a PRESSURE GROUT <br /> 'Other: Grout Specifications: 11exi— cE m6vc� - <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS f <br /> MONITORINGfiOLLOW STEM DIA.OF BOREHOLE_ OJ rr MULTIPLE CASINGS?j]YES Wfd0 WELL CASING DIA: .�� <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL []PVC []OTHER: � <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL . TREMIE TYPE TO BE USED: []AUGERS []HOSE <br /> ©AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: []Yes 0 No (NOTE. MAXIM U M FREE-FALL DEPTH IS 30) <br /> []SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: %4— 9 rp <br /> o OTHER:_0 OTHER APPROX.BORING DEPTH M AX SO AOLTED TRAFFIC BOX or 11 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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x_ ZLA6A-O-A Title/Company S`tGlrl I<ri.Rl nee <br /> Print Name M i—ae ._. ,Teo r+,- Date <br /> DEPARTMENT USE ONLY u <br /> SITE MAP IN UNIT IV FILE, ADDRESS: � /� /3�/ � �.� k-� acid <br /> WORK PLAN DATED: /0 -Z O Z <br /> Application Accepted By Date Issued 1-2-7- 0-5 Area <br /> Grout Inspection By Date Fina!Inspection LETGate 6:Y?—Z—O 3 -_ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE r, PERMIT/SERVICE REQUEST# INVOICE i <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_- 1/25/02 <br />