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0 1 G WAL <br />WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 _G <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 /'2Z-!5 E( dy-e_c) o 5't • Cross Street 1 i, r rd Sf • City Zip Parcel# <br />PROPERTY Owner Address ckt - o� - Lod- City Zip Phone# <br />C-57 Contractor AAddress �'�J (City 5tockfon Zip Sto5 Lic#�8ou7 <br />SF Phone# Log -.4&12 - (oa � <br />Consultant / Sub <br />Contractor PA, /,�p SP� ✓,cr- S Address Z ID t,)c 64 S4,. / 6-n City� ��-%b,, Lic# Phone# l Y - L$ (- l S 4 -7 <br />=,h,e,s 6u.3c <br />o <br />GIS Coordinates: X 3 7 S6At , Y /z! � 17 W ,Township / /Y Range G E Section /O <br />WORK TO BE PERFORMED, <br />XNEW WELL / BORING (34,( 6EOjP�RO6�,HYDROPUNCH, HAND -AUGER, OTHER") p DESTRUCTION (choose type below) <br />LIt # P/�- 6� 7�_ 0 OVER -BORE <br />0 WELL # 0 PRESSURE GROUT <br />`Other: Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS <br />TYPE OF CASING: o STEEL 0 PVC o OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL <br />TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br />0 AIR SPARGE <br />XPUSH POINT <br />GROUT SEAL PUMPED: o Yes <br />p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />'SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS: <br />0 OTHER:_0 <br />OTHER <br />APPROX. BORING DEPTH <br />0 BOLTED TRAFFIC BOX oro STOVE PIPE <br />CONDUCTOR CASING PROPOSED/? ( if YES, list specifications here): <br />"COMMENTS: C?co�Jroht <br />�0 INc 5 fo <br />fje �ti c✓i C10N�C{ tof��W <br />rKc SS ^r�/ K S <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 �s«�/' ..�1 Title/Company /-!� (t✓✓, C e/S <br />Print Name ✓�i�= /tea �� Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: Q <br />WORK PLAN DATED: --x�- p7 <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Inspectic <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />/7/7 5. L'a4c—�-' 5) <br />-0 ■ <br />Date Issued 3 -( Area <br />Date Z Final Inspection By Date <br />Date <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE P RVICE REQUEST # <br />INVOICE <br />"o I <br />151 <br />OZ 3 <br />3'5 0 0 / <br />C-57 ✓ WC / -WAIVER_ C-57 Letter of Authorization to sign permit vfn —'� 1/25/02 <br />l��0o <br />