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WELLhERMIT APPLICATION Rlil SITE <br /> n �T�� - �T 2��3MITIGATION <br /> 'SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT {END} <br /> Vll�0- 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES I 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.Assessor's <br /> WELL )bO 56aW (2.06, rcissStreet rrenon- ity S6cklbyi -zip Parl <br /> PROPERTY OwneEffteAhk 6(� dress Phone# 62 <br /> U - _t!5�?D,7 POO 71B <br /> C-57 Contracto i I.I.I I W.1 I r,kill Afj Y_q,V L I c# 4P h o n 39�53 <br /> Addr ss]" A72t)LgH Cityl <br /> P <br /> Consultant/Sub Cn Address)?2L�I_Adw raa_City342Lkkj1 LickPhone <br /> GIS Coordinates-X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> )WEW WELL/BORING(QPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# [I OVER-BORE <br /> XWELL a PRESSURE GROUT, <br /> *Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SP CIFICATIONS <br /> *ONITORING )%,UOLLOW STEM DIA.OF BOREHOLE&,T MULTIPLE CASINGS?[I MULTI-LEVEL?a WELL CASING DIA: 2 <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL JCPVC OOTHER-_ <br /> []VAPOR a MUD ROTARY DEPTH OF GROUT SEAL'94P TREMIE TYPE TO BE USED: JkAUGERS 0 HOSE <br /> AIR SPARGE/Ozone aPUSH POINT GROUT SEAL PUMPED: %t(es a No (NOTE: MAXIMUM FREE-FALL'DEPTH IS 30') <br /> SOIL BORING [I HAND AUGER GROUT SPECIFICATION�._� 14c-_�l IA_UtCn��AQ44 fp 6q/CL 9, b <br /> OTHER: I]OTHER APPROX.BORING DEPTH . I C)D/ W.BOLTED TRAFFIC BOX or,'[1 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? Ajb (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 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 /> Signe 11 <br /> C_ <br /> d x A— Tide/Company 0 13 <br /> L Gr <br /> Print Name 1 A 0 —Date- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:, [ (-, 4-1 <br /> WORK PLAN DATED: 2-0 . 2 00 <br /> Application Accepted B Date Issued <br /> By -2- <br /> AC%4A Are <br /> 03 <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> -2- 3q 3 IS <br /> -8/29/02 <br /> C-57 WC -WAIVER— C-57 Letter of Authorization to sign permit Encroachment doc— <br />