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. 4 <br />WELL rERMIT APPLICATION FARM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <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 />] �`7 Vv e df r uq P]lt CQ. Cross Street Ci -i- per- Assessor's <br />WELL Location � � I1� '] city 1 G� ] � Zip /537 Parcel# :Z.S�j <br />PROPERTY Owner 41.1 IdC C tFl; rLA� Address ]�/S yD s/�p_;apl t IZc.I Ciry /�L`i �ttFri zip 1XUPhone# 10-324-6277 <br />C-57 Contra C/,[ (3c�E�/✓ Address sl�l Gt.� /�Cc r City c��L%�GI7 Zip SL�'T�Lic#�Phone# D% �o /trYJ� <br />Consultant/ Sub CntrA d04fae16-z a Addressgj7 �((�iht7 /2 City..-Lic#66022 Phone# I OP, <br />GIS Coordinates: X , Y <br />Township Range Section <br />WORK TO BE PER MED: <br />NEW WELL / ORiNG CkOELL <br />EOPROBE YDROPUNCH, HAND -AUGER, OTHER*) <br />G# <br /># <br />*Other: <br />COMMENTS <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE /Ozone BUSH POINT <br />ISOIL BORING <br />0 HAND AUGER <br />0 THER: <br />p OTHER_ <br />Specificati <br />DESTRUCTION (choose type below) <br />OVER -BORE <br />PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE oft " MULTIPLE CASINGS? 0 MULTI-LEVEL? 0 WELL CASING DIA: <br />CASING THICKNESST) A-_ TYPE OF CASING: O STEEL p PVC BOTHER: -A&4' OTHER: -� <br />DEPTH OF GROUT SEAL rr TREMIE TYPE TO BE USED: p AUGERS ZHOSE <br />GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH I5 3C') <br />GROUT SPECIFICATIONS: P49f-1.L**yieey,&cr- A,* v1v h aG W -z- 8 <br />APPROX. BORING DEPTH_ 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED?A/& 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 />Coun Ordinances Ru es and Regulations, and all applicable California State Laws. <br />Signed x Title/Company 2.C)1 t7 6 15�14/`oCL`�� <br />Print <br />L VW <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 10 vii . <br />WORK PLAN DATED: '2600 <br />- ,r <br />Application Accepted By l t e: t Date Issued/ �j Area -1 4 `✓ <br />Grout Inspection By �/�Jr��n_Date Final Inspection By `f ate <br />Destruction Inspection By -_ �� Date <br />COMMENTS/CONDITIONS:?67 <br />ACCOUNTING <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / 9ERViCELREQUEST # <br />INVOICE <br />o <br />C-57 WC_ -WAIVER C-57 Letter of Authorization to sign permit Encroac ment doc 8/29/02 <br />