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WELL k"ERMIT APPLICATION Fk,.�M <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHID) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />ORIGINAL <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 />WELL Location ► i a rN� �,>~,, PI cis Cross Street -7-� Assessor's <br />1I, _ 1 i �1 D City 6 Rr� Zip A Parcel# <br />PROPERTYOwner )IOVyL Q-�wrCj^ Address W �O)( 4S City C Zip 'l537hPhone# <br />C-57 Contracto&/QWI:C/.(cJ/V Address &Sy[�l.Gt.�/U Cityc5iDL��Y/r1 Zip ELic# ,� Phone <br />�# C9 <br />Consultant/ Sub CntrA dva*� � 6 &� Address9j7.$�ha ,7 /[GC Cit �Lic#6la'dZ� Phone#_aa__ 4,61 Z —06 <br />GIS Coordinates: X <br />Y <br />Township <br />Range <br />WORK TO BE PER MED: <br />NEW WELL / OR1NG IC GE RRN <br />HYDROPUNCH, HAND -AUGER, O7NER*) <br />x # <br />Q WELL # <br />*Other: <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE <br />O MONITORING 0 HOLLOW STEM <br />Q EXTRACTION Q AIR HAMMER/DRIVEN <br />Q VAPOR Q MUD ROTARY <br />Q AIR SPARGE / OZone,�I<FUSH POINT <br />'TOIL BORING Q HAND AUGER <br />0 OTHER: _j] OTHER <br />Grout Specifications: <br />Section <br />Q DESTRUCTION (choose type below) <br />Q OVER -BORE <br />Q PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE r,2 - MULTIPLE CASINGS? Q MULTI-LEVEL? Q WELL CASING DIA:AiI C) <br />CASING THICKNESS_ TYPE OF CASING: Q STEEL Q PVC 0 OTHER:. C� <br />DEPTH OF GROUT SEAL 1;j&4- TREMIE TYPE TO BE USED: Q AUGERS THOSE v <br />GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE -FALL DEPTH IS 3t.,') <br />GROUT SPECIFICATIONS:J}JYL,t Lz'GKvc-f iib <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or Q STOVE PIPE L <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br />*COMMENTS: <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 />Count Ordinances, Rules and Regulations, and all applicable California State Laws. _` <br />Signed x _ f,,( / ' 1 Title/Company 2C3t U` 15 T MUA � r 6 �E c <br />Print Name � � L f� l V� t -r Date (.c2� _ <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 10 W 3e✓e- lad-, e- j ra &-,i <br />WORK PLAN DATED: JO r? 0 44 r4 2 Ot5 i) <br />Application Accepted By fo r ' ,= r Date Issued Area 4 s q <br />Grout Inspection By Date Final Inspection 3y I ate G <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: f r AR n f> r -1 (4� '. 619 <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />INFO <br />AMOUN9T R�E)Mr TED <br />AMOUNT <br />CHECK <br />REC'D BY <br />DATE PER/M[� UEST # <br />INVOICE <br />5F/.�EEE <br />�V l i L� V <br />/# <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc 8/29/02 <br />