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Ruj'ts I jy� 1� WELL PERMIT APPLICATION FORM <br />�OaLok S VJ I �v SAN JOAQUIN COUNTY <br />AUG 10 ZIRONMENTAL HEALTH DEPARTMENT (EHD) <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />4 E. Weber, Third Floor, Stockton, CA., 95202 <br />ENVIRONN9EN1 HEALTH (209) 468-3449 <br />PERMIT/SERV1C,F6-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 hV4111 Ae1//i LK - Cross Street <br />� /1 / % Ci Lt Zip <br />1 67Lt Parcel#A!6_0 <br />PROPERTY Owner 5FlTr"�RAa 147 e AddressYJD 716!5 /Zt/c{ Citi /,W. N-7- `�Z 6070 4 Phone# <br />C-57 Contracto �( n J Address t d Cit (AG Zin4C,640 Lic#Phone# C{�b) <br />r__ f _ ' I p v' a P <br />Consultant/ Sub Cnt y'(�IrtG4AJ�(9NW�W6JAddress It �� aW - � ` it Lic#QV �730� Phone# I - (. <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />jNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />0 SOIL BORING # <br />`�W E LL # C,1i(),It <br />*Other: Grout Specifications: <br />COMMENTS <br />TYPE OF WELL <br />INSTALLATION TYPE <br />Y11ONITORING <br />IN IOLLOW STEM <br />r0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE / Ozone 0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER: <br />0 OTHER <br />'COMMENTS: <br />C_ <br />0 <br />0 DESTRUCTION (choose type below)Cn <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS %r <br />DIA. OF BOREHOLE a MULTIPLE CASINGS? 0 MULTI-LEVEL? 0 WELL CASING DIA: Z IDE <br />CASING THICKNESS. 5(z�1140 TYPE OF CASING: 0 STEEL �VC 0 OTHER: <br />DEPTH OF GROUT SEAL_ T,____.1 TREMIE TYPE TO BE USED. ?3ZUGERS 'POSE <br />GROUT SEAL PUMPED: Ryes 0 /No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS`: V tAPZA4- C <br />APPROX. BORING DEPTH 1.�S'OLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (J 0 ( 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 Ordird*,gs,, Rules and Regulations, and all applicable California State Laws. <br />Signed x <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />/216 F <br />LD, 20 v 3 <br />Sft- - (40 <br />Application Accepted By Date Issued <br />��� <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection <br />COMMENTS / CONDITIONS: <br />Date <br />it&LtC*Vlevtfwewvj <br />to <br />)6 �(/ <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />350 1 <br />t4\W <br />25 <br />C-57 ✓ WC ✓ -WAIVER_ C-57 Letter of Authorization to sign permit_ n oc�,V/,i 8/29/02 <br />