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WELL PERMIT APPLICATION FORM -ORIGI L <br />SITE <br />SAN JOAQUIN COUNTY MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />SEP 10 ZW3 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />ENVIRONMENT HEALTH (209) 468-3449 Dl , <br />PERMIT/SERVICES 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 9-11115.3 and the Standards of San Joaquin County Environmental Health Department. <br />I ` ' \ `1 1- �, p C -I/ Assessor <br />WELL Location � wn -, �� Cross Street Ci Zi I �G�� �` �I�' Parcel# G <br />PROPERTY Owner City�o�n fZD- j) Zipq'jC, Phone# j� 7N3' %U�3 <br />C-57 Contractor_ ja `eLck /Gl�� LliyAAddress City Zip LJic#]l Phone# <br />Cn J� b� <br />Consultant / Sub Cntr 11 ______,Address �� 5� � �cd City S ?V1 Lic# C6 Phone#) 107 f 63b <br />GIS Coordinates: X <br />Y <br />Township <br />Section <br />WORK TO BE PERFORMED: / <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) DESTRUCTIQ14(choose type below) <br />0 SOIL BORING # _ / \ OVER -BORE <br />0 WELL # �rL; J PRE <br />'Other: Grout Specifications: -yb AA vl � I �)A SURE GROUT <br />COMMENTS <br />TYPE OF WELL <br />INSTALLATION TYPE <br />[] MONITORINGHOLLOW <br />STEM <br />EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />11 VAPOR <br />0 MUD ROTARY <br />o AIR SPARGE 1 Ozone 0 PUSH POINT <br />iJ SOIL BORING p HAND AUGER <br />OTHER (mi i rli 0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 MULTI-LEVEL? a WELL CASING DIA: <br />CASING THICKNESS- A) _TYPE OF CASING: I] STEEL 0 FVC a OTHER:____ <br />DEPTH OF GROUT SEAL,fi) TREMIE TYPE TO BE USED: D(AUGERS 0 HOSE <br />GROUT SEAL PUMPED: a Yes p No (NOTE: MAXIMUM FREE -GALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH --, BOLTED TRAFFIC BOX or a 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 />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed z <br />Print Nai <br />SITE MAP IN UNIT IV FILE, ADDRESS--:'' <br />WORK PLAN DATED: 21 4t) <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Insoectio <br />COMMENTS / CONDITIONS: f <br />ULPAK I MtN 1 U,t UNLT <br />Date Issued _ . >Zw;(illi� "_ Area <br />Final I nspection By '? ! Date <br />Date 9,14- 3 i> <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED CHECK # <br />REC'D BY <br />DATE P UEST # INVOICE <br />3562- <br />I <br />! g 19 3.1? <br />-ID D S22o <br />C-57 WC WAIVER C-57 Letter of Authorization to sign per mit--'2fTncroac men oc 8/29/02 <br />EM <br />