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WELL h ERMIT APPLICATION FOM <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 />_ Assessor's <br />WELL Location / - Cross /Street 1.0 — City .S, G o� Parcel# 7 v t7 l <br />PROPERTY Owner ��7 Address �G 7`�/r`)'e Z City. G- <br />Zipq!5�3I Phone# 7 y — Z <br />rl I Address / City J / <br />C-57 Contracto 7 r �>1 �' �► �� �/� Ci Zi ic#i6 PhoneP/Z5 E/3 <br />Consultant/ Sub Cntr 'AGAddress % S e'�_ City_ L4- 4 Lic# Phone# <br />GIS Coordinates: <br />Y <br />WORK TO BE PERFORMED: <br />0 NEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />SOIL BORING # <br />0 WELL # <br />Range Section <br />p DESTRUCTION (choose type below) �1 <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />*Other: <br />PE CODES <br />Grout Specifications: <br />AMOUNT REMITTED <br />COMMENTS <br />REC'D BY <br />DATE PERMIT I-SERYICE REQUEST # <br />21 <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />0 MONITORING <br />0 HOLLOW STEM <br />DIA. OF BOREHOLE-2/f),CA MULTIPLE CASINGS? 0 MULTI-LEVEL? p WELL CASING DIA: N <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS 1l/%t' TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />d <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL/b0 i:—�-- --TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE / Ozone BUSH POINT <br />GROUT SEAL PUMPED: 'SYes 0 No (NOTE:)WAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS: <br />0 OTHER:___o <br />OTHER <br />APPROX. BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />_1 <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS: <br />-�Gi t�l' J <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company <br />Print Name ki, / � �l _ h I y� � Date r -d <br />DEPARTMENT USE ONLY <br />n- C <br />SITE MAP IN UNIT IV FILE, ADDRESS: '5) <br />WORK PLAN DATED: 7 <br />Application Accepted By a <br />Grout Inspection By _ Date I I / <br />Destruction Inspection BY'-/ W Date <br />COMMENTS / CONDITIONS: <br />Date Issued / t-' // !/"�' z Area <br />Inspection By <br />Date <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT I-SERYICE REQUEST # <br />INVOICE <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encro ent doc 8/29/02 <br />