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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 Developme t Tfl , Ch ter 9-111 5 3 and the Standards of San Joaquin County Environmental Health Department. <br />//�D^^^ ^n (�-� Assessor's <br />WELL Location EcL5E�TLia.amCross Street City 5�Dc,�i�r�..r Zip Parcel# <br />k 2 <br />�e <br />PROPERTY Ownerd 14�) 43-w-",- Address 34S 1(4. F IP br6An City SSAUjjt., Zip Phone# <br />C-57 Contractor tenor ,..4�Ya ,,. AddressZ14w&L"o CityZip SlZZ6 Lic#Phone# 465-SJIZ <br />qo�ultanDtSub Contractor 1,/t, tvl a," I� fsAddress 11ILI VvVLn, S'_iif City S�Lic#Gjg5 Phone# 93R- kW <br />GIS Coordinates: X , Y - , Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type be!ow) <br />0 SOIL BORING # 0 OVER -BORE <br />WELL # VM&w (Z 0 PRESSURE GRCUT <br />*Other: A—Grcut Specifications: hxk4:: cew+9=,�& <br />COMMENTS: �Al/� {?e(W�+03-l�Ow <br />TYPE OF WELL <br />INSTALLATION TYPE <br />`-'MONITORING <br />'6}- HOLLOW STEM <br />0 E <br />EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER: <br />0 OTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE�MULTIPLE CASINGS? 0 YES ;I(NO WELL CASING DIA: <br />CASING THICKNESS SC A qt) TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br />DEPTH OF GROUT SEAL$���TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br />GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: k, ,, rQu,a,.3 <br />APPROX. BORING DEPTHSD )VOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? N_) (if YES, list specifications here): <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 07dina5"Rules and Regulations, and all applicable California State Laws. <br />Signed <br />Print Na <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />ate 1013616 <br />Application Accepted By Date Issued Area <br />Grout Inspection By { Date f 15 Final Inspection By Date <br />Cestructicn Ir.sc=ction By Date <br />CO%1NIENTS ! CONDITIONS: K "V G-1- j t 0P L, -.x f) -z A-22, <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />I FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />P UEST # <br />INVOICE <br />v/ <br />l <br />%R# <br />o <br />C-57 -- WAIVER_ C-57 Letter of Authorization to sign permit Encroac ment doc 1/25/02 <br />