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&"arKSiC &-.v-3-6q-( WELL PERMIT APPLICATION FORM <br />[RECEISED SAN JOAQUIN COUNTY <br />AUG 10 2t VIRONMENTAL HEALTH DEPARTMENT (EHD) <br />`' 4 E Weber Third Floor Stockton CA 95202 <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />ENVIRONMENT HEALTH, (209) 468-3449 <br />PERM IT/SuERVICFJNON-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 1(og E. er�W. CrossStreetQeK�'��city S'ECO k;� Zip Parcel# Og4-0 0—h <br />/lubumda(P Flv jg E K ddress Z%( U65i, s'EQ Z05V City t iu Zi 0 D5 Phone# 0 <br />PROPERTY Owner y� L- <br />C -57 Contractor ' + A Y (_ CU4- Addrres/s �� �^ Ci ZipgSWLicPhone# <br />L66Consultant/Sub Cntr,HDY��o�►G></JLf0ti1'uRAAddress�I�Wf�(►�1ity 4 �( Lic#'W 5� Phone# �l <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />'2-4EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE <br />IMELL # I Aw 0 PRESSURE GROUT Cs <br />'Other: I t1r I Grout Specifications: c,.A_ <br />COMMENTS <br />TYPE OF WELL <br />INSTALLATION TYPE <br />MONITORINGOLLOW <br />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: <br />0 OTHER <br />'COMMENTS: <br />CONSTRUCTION SPECIFICATIONS {{,,�� [� �I <br />DIA. OF BOREHOLE MULTIPLE CASOGS? 0 MULTI-LOV L? 0 WELL CASING DIA: <br />CASING THICKNESS SG h.0 TYPE OF CASING: 0 STEELA2VC 0 OTHER:_` <br />DEPTH OF GROUT SEAL ?J51 <br />__ TREMIE TYPE TO BE USED: )N UGERS °$;NOSE <br />GROUT SEAL PUMPED: Yes 0 No(NOTE: MAXIMUM FREE -FALL DEPTH IS 30') C` <br />GROUT SPECIFICATIONS:yi&k_C"W} <br />APPROX. BORING DEPTH 6O r C B LTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED?— ( 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 />Cou <br />Signe <br />Print <br />SITE MAP IN UNIT IV FILE, ADDRESS <br />WORK PLAN DATED: <br />Application Accepted By_ <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />ULIJAK I MIN I UJt ONLY <br />?,got <br />Date Issued Area <br />Date Final Inspection By Date <br />Date <br />ACCOUNTING ONLY: <br />AID# FACO <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK2# RECD BY <br />DATE <br />PERMIT ICE REQ T # <br />INVOICE <br />3S� <br />it <br />b <br />C-57_ WC V -WAIVER_ C-57 Letter of Authorization to sign permit__-17 <br />ncro ment doc/,/ 8/29/02 <br />