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WELL PERMIT APPLICATION FORM <br />MVS' 10RECE W E D`"' SAN JCAQUIN COUNTY <br />AUG 10 200VIRONMENTAL HEALTH DEPARTMENT (EHD) <br />4 E. Weber, Third Floor, Stockton, CA., 95202 <br />ENVIRONMENT HEALTH (209) 468-3449 <br />PERMIT/SERVICES <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 />Assessor's <br />WELL Location �2�2 �L(yT G%(�KQ�%(IM• Cross Street <br />� P1y� pity <br />�4_Zip Parcel#�q_03Z <br />D-1 <br />3 <br />PROPERTY OwneAbKv1"(e PrOPIQ�S(ddress%("S* L050CiitA"'ta Zi�ogo5Phone# ?D(o'3j <br />C-57Contractor t,e W: �V- Address10y01�t461?Alk CiWALV,"Zip Sb�Lic#6'�l-fPhone# (10 45 <br />colrocorvv— <br />1, <br />Consultant / Sub Cntr city&>,6"Lic# Z530'Phone# <br />-r— <br />GIs Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />,24lLEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) <br />0 SOIL BORING # <br />�NELL # MW" LO <br />'Other: Grout Specifications: <br />COMMENTS <br />TYPE OF WELL <br />INSTALLATION TYPE <br />'"ONITORING <br />VOLLOW STEM <br />0 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: 0 OTH <br />`COMME <br />0 DESTRUCTION (choose type below, <br />0 OVER -BORE (� <br />0 PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS !v 6/J� u <br />DIA. OF BOREHOLE_ MULTIPLE CASINGS? 0 MULTI-LAL? 0 WELL CASING DIA: <br />CASING THICKNESS. O TYPE OF CASING: 0 STEEL NgVC 0 OTHER: <br />DEPTH OF GROUT SEAL 35' TREMIE TYPE TO BE USED: AUGERS ?�SE <br />GROUT SEAL PUMPED: Xyes - I0,NNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: Vel Ca,04at / <br />APPROX. BORING DEPTH E7 t OLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED?_NV ( 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 Ordy"4es, Rules and Regulations, and all applicable California State Laws. <br />Signe <br />Print <br />DEPARTMEN I USE UNLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: /Z/U �' <br />WORK PLAN DATED: `lam-, /0i .2�3 <br />Application Accepted By <br />Grout Inspection By_ <br />Destruction Inspection B <br />COMMENTS / CONDITIONS: <br />Date Issue <br />Final Inspection <br />Date <br />0 <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PER I SERV REQ T # <br />INVOICE <br />913 00.3q q <br />1 <br />C-57 ✓ WC ✓ -WAIVER_ C-57 Letter of Authorization to sign permit_ En x On d o c ✓ 8/29/02 <br />Q,Gc c o� tP.i �(-7 <br />