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WELL PERMIT APPLICATION FORM <br />3 SAN JOAQUIN COUNTY <br />C.P� <br />c� ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />F11 r COPY <br />SITE <br />MITIGATION <br />UNIT IV <br />ON' <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 />WELL Location a -1.g4 E. f i e fKpx ci 1 • Cross Street t Assessors <br />I / � F' I be/�pr 5?. City STO�kT 14� Zip yJ` aDs Parcel# /Jr.3 ' a� <br />PROPERTY Owner f OA ��i�!/ Agd`dress? V- SDX 7�4 l City 1444 lk Zip W 5i0 Phone# +6y5�`3�� <br />C-57 Contractor(rf'CfQ.rtllinQ $Tv1S)1a Address_ . 06we R� City /112Z Zip�ySfYLic# $S Phone#9a5 <br />VVJJ r p s o l <br />Consultant/ Sub Cntr (4101` r t4 GhVIr&VN41iQIAddressoZ7Q Perk)YLS 61— City &400) Lic# Phone# 7112133 —^SKF <br />GIS Coordinates: X , Y. <br />Townshi <br />Sectio <br />WORK TO BE PERFORMED: <br />[] NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) [] DESTRUCTION (choose type below) <br />SOIL BORING # 68-13, -1 S -15' [] OVER -BORE. DIAMETER <br />HWELL#5-3-85 S�]" 5, 5-y-85 n PRESSURE GROUT <br />[]'Other '� t GROUT SPECIFICATIONS <br />COMMENTS: _ A//AJ A <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />)`MONITORING )HOLLOW STEM DIA. OF BOREHOL " . [] MULTIPLE CASINGS [] MULTI-LEVEL WELL CASING DIA: <br />[] EXTRACTION [] AIR HAMMER/DRIVEN CASING THICKNESSA qG) TYPE OF CASING: [] STEEL ,(PVC [] OTHER: <br />[] VAPOR XMUD ROTARY DEPTH OF GROUT SEAL 70' TREMIE TYPE TO BE USED: [] AUGERS XHOSE <br />[] AIR SPARGE/ OZONE [] PUSH POINT (GP or CPT) GROUT SEAL PUMPED: XYes [] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30) <br />)ISOIL BORING [] HAND AUGER GROUT SPECIFICATIONS 644U.10 �T <br />[] OTHER: [] OTHER APPROX. BORING DEPTH SSS WelIS l�D�j BOLTED TRAFFIC BOX or []STOVEPIPE <br />11 <br />CONDUCTOR CASING� PROPOSED_yCs (if YES, list specifications in comment section) <br />COMMENTS: S_1-55 L0110Df Im-izlKOA W11in �i CMutALtW CASJA4 GiOlt� 1rJ ^� 70�Q'Cel Ot�)AIr4L4C, <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR 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 Ordinnance,pjFlo&,enj,fgulations, and all applicable California State Laws. <br />Signed <br />Print Nam <br />SITE MAP IN UNIT IV FILE, ADDRESS:_ <br />WORK PLAN DATED: t'o/--:� o 2- <br />Application Accepted By. <br />Grout Inspection By <br />Destruction Inspection <br />COMMENTS / CONDITIO <br />Title/Com <br />DEPARTMENT USE ONLY a <br />7 i ` 7 o--' <br />Date <br />!v•zo.o2. <br />_Date Issued // + �° 0 -2— Area <br />nal Inspection By ate 1-` �o � 3 <br />r. <br />fes' <br />1 <br />.Z' <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE <br />PERMIT/ SERVICE REQUEST # INVOICE <br />jr <br />C-57 WC /-WAIVER_ C-57 Letter of Authorization to sign permit .' Encroachment doc_ 9/30/02 <br />/V� i .�x.caaC.cd <br />