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go] IN 19111 <br />WELL PERMIT APPLICATION FORM SITE <br />''r;v`4Lill -' Iif=.41-1� SAN JOAQUIN COUNTY MITIGATION <br />PE CODES <br />tNVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />AMOUNT REMITTED <br />UNIT IV <br />REC'D BY <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />PERMIT / SE VICE REQUEST # INVOICE <br />02 FEB 19 4,11 9: 47 (209) 468-3449 <br />Off -Goy <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SPeCrxoM <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 />1 l _ Assessor's <br />WELL Location 172n6 E� Do+cdo Stet Cross Street -1-J 5t` -a City S-EoCiCfOn Zip Parcel# <br />PROPERTY Owner e,{y o� StoC&CA Address R II�t-p4- lac./ City Zip Phone# <br />C-57 Contractor SIncC-tr wti Address Z36S IJ aA e-^" City StocKf,3,t Zip LO Lic#512,0//hone#Log-¢65- $7/Z <br />eol�Mb,� <br />Consultant/Sub/ 1/I40Is <br />Contractor P����� Se.✓Ji(es AddressLlO IJcSt 5K,".,.tk City 4423` Lic# Phone# <br />o o <br />GIS Coordinates: X 37 56 1� Y Z 1 ! 7 W Township -F I N Range R C E7 Section /V <br />l3� <br />WORK TO BE PERFORMED: <br />NEW WELL /BORING (CPT GEOPROBE, HYDR1111 inir H HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />SOIL BORING -4--4 0 OVER -BORE <br />(M <br />SWELL # WW 0 PRESSURE GROUT <br />'Other: Grout Specifications: <br />-� <br />COMMENTS: �j ,., J. Y Z ((J <br />9- <br />0 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />XMONITORING(y4v-4) XHOLLOW STEM DIA. OF BOREHOLE `� LS " MULTIPLE CASINGS? 0 YES XNO WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 7. " TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Z.0 ' TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br />0 AIR SPARGE\\ PUSH POINT GROUT SEAL PUMPED: 0 Yes XNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />$SOIL BORING?A) 0 HAND AUGER GROUT SPECIFICATIONS: Ce,*�Id.vf j�✓ov..t <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH=�L,, C� pN BOLTED TRAFFIC BOX oro STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ��O ( if YES, list specifications here): <br />'COMMENTS: Well C4 -Ad 10 v 146 A 441) je s � p I!4) b y <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 P� i X --D5a ✓/✓rCe,S <br />Print Name ���k �// J.c Date Z- ! 0 Z <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: %Z`f _ O/ <br />Application Accepted By <br />Grout Inspection By <;4/251 <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: �S <br />Date Issued_ <br />Date 3' ��' 2 Final Inspection <br />Date _ <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SE VICE REQUEST # INVOICE <br />C-57 WC ✓-WAIVER_ C-57 Letter of Authorization to sign permit ✓Encroac me c_ 1/25/02 <br />