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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <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 />y oe Pc•v+hc Assessors <br />WELL Location Z Ci S W Aft L" Ne R -A Cross Street Pof+w-ty City -Ti -04 Zip Parcel# 2114-01-017 <br />PROPERTY Owner 5 , ej) 0 it products Address 10gkE City Ca, -Sc -.1.0 CA Zip 4?09,(0Phone# J" �'ys=93o6 <br />1' �13b ii ewe `�4ss3Lic# 4S I Phone# 4ZS 3i3 -S a0 <br />C-57 Contractor GCe �^ i L n �i Address City I�ar�'I L Zip �S <br />Rur\Cho <br />Consultant / Sub CntrSRCOZ -r- poli ioncilAddress 367 1-j' 15 C,. e- QJ-, S>'e WLCity Co Idc;✓) 0, Lic# tS 4H y S Phone# i4l d) 861'04 00 <br />GIS Coordinates: <br />Y <br />Township 2 SOUtti <br />WORK TO BE PERFORMED: <br />XNEW WELL / BORING (r.PT (:EOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />'SOIL BORING # <br />AWELL# MW- ,MW—�j <br />[] *Other <br />COMMENTS: <br />Range 5 F—oLst Section 11 <br />[] DESTRUCTION (choose type below) 1�lj``\\ <br />[] OVER -BORE. DIAMETER Vv <br />[] PRESSURE GROUT -� <br />GROUT SPECIFICATIONS <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR 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 />Signed f, Title/Company Pr`;,�-ect ( ecko5Si- <br />S- S i�� <br />CurZ +err`o,+(o(.al <br />Print Name Rr-LA. Cm( -e4 Date �A/04 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE,DR SS: A S �0 C-, <br />WORK PLAN DATED: 3�l �Cy <br />Application Accepted By Date Issued -•' 7- 6, fo Area 6 Z 1 <br />Grout Inspection By ( 1 rot Date Final Inspection By _Date(, IX[t,N a?i� <br />c <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />DATECE REQU T # <br />-c o SR# � �(jZS <br />MONITORING <br />HOLLOW STEM -Wells <br />DIA. OF BOREHOLE [] MULTIPLE CASINGS [] MULTI-LEVEL WELL CASING DIA: Z <br />� <br />[] EXTRACTION <br />[] AIR HAMMER/DRIVEN <br />CASING THICKNESS Sc -I\ 4 O TYPE OF CASING: [] STEEL )f' PVC [] OTHER: <br />-�- <br />[] VAPOR <br />[] MUD ROTARY <br />DEPTH OF GROUT SEA TREMIE TYPE TO BE USED: )Z -AUGERS [] HOSE <br />5 <br />[] AIR SPARGE/ OZONE <br />PUSH POINT (GP ori :PT <br />GROUT SEAL PUMPED: [] Yes ) No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />ra <br />SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS_ 31 <br />[] OTHER:_0 <br />OTHER <br />APPROX. BORING DEPTH_V7 7 _ABOLTED TRAFFIC BOX or STOVE PIPE 1 e—t-- <br />CONDUCTOR CASING PROPOSED N 0 (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR 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 />Signed f, Title/Company Pr`;,�-ect ( ecko5Si- <br />S- S i�� <br />CurZ +err`o,+(o(.al <br />Print Name Rr-LA. Cm( -e4 Date �A/04 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE,DR SS: A S �0 C-, <br />WORK PLAN DATED: 3�l �Cy <br />Application Accepted By Date Issued -•' 7- 6, fo Area 6 Z 1 <br />Grout Inspection By ( 1 rot Date Final Inspection By _Date(, IX[t,N a?i� <br />c <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATECE REQU T # <br />-c o SR# � �(jZS <br />INVOICE <br />�501065.00 <br />'5-�3o3b <br />(tiQ <br />C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit Encr 9/30/02 <br />