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WELL PERMIT APPLICATION FORM SITE <br />SAN JOAC>~UIN COUNTY MITIGATION <br />UNIT IV <br />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 />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 />//�� Assessor's <br />WELL Location � Cross Street Sf� City SwC �c Zip Parcel# <br />1" eo j3�,'1c ,. r 1 <br />PROPERTY Owner Add res-11� City Zip hone# <br />C-57 Contractor I l f Address �bLZD�L 141b city Zip 41 / Lic# 7LU ioyPhone# 1i /6 %77-z1 /U U <br />Consultant / Sub Contractor Zi -,7n Address I 1 LY m S-k�+- City ES Lic# Phone# &3�- q kw <br />GIS Coordinates: X <br />Y <br />Township Range Section <br />WORK TO BE PERFORMED: <br />AMOUNT REMITTED <br />0 NEW WELL / BORING <br />(CPT. GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) DESTRUCTION (choose type below) <br />DATE <br />0 SOIL BORING # <br />X.OVER-BORE <br />35ic) <br />WELL # ZjVj I <br />^, ff PRESSURE GROUT <br />'Other: <br />Grout Specifications:IrI �rA� <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />n <br />CONSTRUCTION SPECIFICATIONS: C SG[ale/I j i� "Cvv�$- Ck <br />0 MONITORING <br />HOLLOW STEM <br />DIA. OF BOREHOLE_ MULTIPLE CASINGS? 0 YES 0 NO 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 (7;. S TREMIE TYPE TO BE USED: 0 AUGERS KHOSE <br />0 AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED:/)CYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS: t <br />0 OTHER <br />0 OTHER <br />APPROX. BORING DEPTH L 7, 5 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 Ord ai}ces, Rules and Regulations, and all applicable California State Laws. / <br />Signed x // Title/Company C\��7, PD�OGi.f f ���D7rxlCP Z�(U <br />Print Name �AJ Date I t IZ710 1 - <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: `C <br />WORK PLAN DATED: -1161 L Z <br />Application Accepted By �� - Date Issued 1 1 1 d / d 3 Area <br />Grout Inspection By Date , Final Inspection By Date <br />Destruction Inspection By L/1') , Zn'Scb Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />I <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />35ic) <br />(0C <br />o <br />I alL <br />3 ;u3-7 <br />C-57_ WC= WAIVER C-57 Letter of Authorization to sign permit oocnm-.�--- <br />1/25/02 <br />S � C 0 3 Z'� i7 2-�, <br />