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• WELL PERMIT APPLICATION FORM <br />!� ti jj�t''ftit.i NJ Ai. HEAI-W SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />.48304 E. Weber, Third Floor, Stockton, CA., 95202 <br />1o09 (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 />//� zz�7 /� P%ANNZ0Q 19, - Assessors <br />WELL Location IC�yJ / �' ' ��N N �1� &C •Cross Streeet7 Tjq,rv,-tir� �,l'. City / ZSip` �is°7y S Parcel# C55 ^32 a ^ /� <br />PROPERTY Owner l:l h ( j l`1yu � t? Address_ lO 7 /6p -5T City59u�',my-i kziip 95b'l t/ Phone# I/ ( -Y93 - O&V Q <br />C-57 Contractor2�, E _ Address j % S I i# w I D City 5.-/ <br />t^Zip Lic# &'�UeZ (Phone# 0`1 <br />Consultant / Sub Cntr . (o F __ Address 'J3 7 5/ 4v,/ R D City S 10k -l( V-, -� Lic# Cc$w 2 t 7 Phone# L 'J i Y 6 7 —10& t <br />GIS Coordinates <br />Y <br />Township <br />Range <br />Section <br />WORK TO BE PERFORMED:, <br />NEW WELL / BORING ((:�-T, GEOPROBE, HYD PUNCH, HAND -AUGER, OTHER`) DESTRUCTION (choose type below) <br />SOIL BORING # �/ 11 o OVER -BORE <br />0 WELL #% 0 PRESSURE GROUT <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 />p AIR SPARGE / Ozone PUSH POINT <br />.SOIL BORING <br />,OTHER:_ <br />p HAND AUGER <br />0 <br />p OTHER <br />Iiii0Z67Ni <br />Grout Specifications:_ u r 1 —19£ <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE z ,, MULTIPLE CASINGS? 0 MULTI-LEVEL?19 WELL CASING DIAlvl'� <br />CASING THICKNESS 114va TYPE OF CASING: [I STEEL 0 FVC 0 OTHER: <br />DEPTH OF GROUT SEAL S,5 F 1 TREMIE TYPE TO BE USED: 0 AUGERS SE <br />GROUT SEAL PUMPED: Q Yes p No (NOTE: MAXIMUM F EE -FALL DEPTH 30') <br />p <br />GROUT SPECIFICATIONS: 7 o R 1 %O Np T� <br />APPROX. BORING DEPTH 51� 1 � T• a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CASING <br />( if YES, list specifications here): <br />Q3 O <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_: � Title/Company tj' t_ t C •/ 6i o/ 05 <br />Print Name / / ,� O 7wy �', ` v4M,Date OIL Q71 oV <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: G <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Insaectio <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />3 <br />Date <br />Final Inspection By <br />/- <br />Low. u� <br />v6 <br />W <br />=\ <br />L <br />Q <br />s <br />ACCOUNTING ONLY: AID# <br />C-57 <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PE VI/CE R INVOICE <br />✓� ( <br />-r <br />/-Z- <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Enc n oc 8/29/02 <br />