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WELL ERMIT APPLICATION FL - .M SITE <br />SAN JOAQUIN COUNTY MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) P �10 <br />304 E_ Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 JUL 1 1 2003 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NVIR(1NMENT F EALTH <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is macf�FjCOMN,4f a -fan <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. ''= ''p / g <br />Assessor's <br />WELL Location c1 S. Cross Street Ci ty `��TL� �L (1 Zip P rcl#a/ b �Q8o 1 <br />PROPERTY Owner >CL� J �>� �L� I Address 1r()j City"jjk D Zip i Phone# <br />C-57 Contractor n(5� t, Address x ��('1 '� CityL ZIpC Phone# ,� ��{ ✓v "�GIL�k <br />Consultant / Sub Cntr� I Address --?7 `7�, \u City L 1 Lic#� 0 n Phone# \(,j <br />GIS Coordinates: X Y Township �� (� Range � ��d`�) Section 3 a n t�st <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 11 DESTRUCTION (choose type below) <br />SOIL BORING # OVER -BORE <br />0 WELL #` PRESSURE GROUT <br />*Other: Grout Specifications: )'� <br />COMMENTS <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />`HOLLOW 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 />SOIL BORING <br />0 HAND AUGER <br />p OTHER: <br />IKOTHER " 0 0k <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE_ MULTIPLE CASINGS? a MULTI-LEVEL? fj WELL CASING DIA: ' <br />CASING THICKNESS 1 i (PE OF CASING: []STEEL B PVC BOTHER: <br />DEPTH OF GROUT SEALGx I TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br />GROUT SEAL PUMPED: 0 Yes � No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: ootA la J C l� VVI vi� <br />5,PPROX. BORING DEPTH—� <C.) hy, a BOLTED 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 />�1 <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 �� `"n-' — `�', �`l.Company r 1 C V ) fi <br />Print Name �(41� '(� ��/� I �, Y Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: „ <br />Application Accepted By V \ • V\_; Date Issued_ <br />Grout Inspection By Date _ __ nal Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDMONS: <br />—11—G <br />�✓ <br />Aa" <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REVD Y <br />DATE <br />PERMIT VICE REQUEST # <br />INVOICE <br />C-57 WC -WAIVER C-57 Letter of Authorizat� to sign permit c 8/29/02 <br />V, <br />