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WELL PERMIT APPLICATION FORM <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 />W-LftW/SbquIS(aus Assessor's <br />WELL LocationSB lrYxjg. Pk< Aria Cross Street City 41- Zip Parcel# <br />PROPERTY Owner Sf(7G/G k, Address rr} S4- City 5)0r Zip Phone#l7.37�'.306 <br />C-57 Contractor Vg L., I)[-,lltIt4 Address %K Lot City a Zip 441 Lic#%2G goy Phone#�}/6��7%�IIUU <br />Consultant/ Sub Contractor 6r&AAAJ LerQ Address I1 ISI kA6Unn S+CM F- City S�� Lic# Phone# S3�-59ff <br />GIS Coordinates: X <br />Y <br />Township Range Section <br />WORK TO BE PERFORMED: <br />FEE INFO <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) )eDESTRUCTION (choose type below) <br />CHECK # <br />0 SOIL BORING # <br />0 OVER -BORE <br />PERMIT / SERVICE REQUEST # <br />`$WELL # VJAA) Z <br />'-/DRESSURE GROUT <br />`Other: <br />/~ <br />Grout Specifications: wce-t - � u4a+ <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS' See .4Al l09 �ef�Cr,N,g�plQ�eu Q <br />0 MONITORING <br />0 HOLLOW STEM <br />DIA. OF BOREHOLE S � � MULTIPLE CASINGS? DYES ONO WELL CASING DIA: <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL 4L) TREMIE TYPE TO BE USED: D AUGERS g HOSE <br />0 AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />D SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS: <br />0 OTHER:_O <br />OTHER <br />APPROX. BORING DEPTH CJ' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />'COMMENTS: <br />NOTE: <br />OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Oridinances, Rules and Regulations, and all applicable California State Laws. / <br />Signed x Title/Company-,Pyio�6 <br />Print Name S_POi,3 6C1.rs)24/ Date ll�L7w z <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 1;L-1 10 I b Z <br />Application Accepted <br />Grout Inspection <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date <br />ate Issued/ 6 Area <br />inal Inspection By Date <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />3S6 <br />lD <br />$ to -o <br />P <br />C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ En oc 1/25/02 <br />S>�ov 3-Z <br />