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Vv 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 />ORIGINAL <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 />WELL Location -5,1440 Y1 S+Yeef Cross Street City 7 Zip Parcel#15}- o -bZ <br />PROPERTY Owner__lay(y N0{Qr} J Address f Cit <br />� y i(w Zip 3 Phone# C 0 iTC <br />o ' �I�wel n <br />C-57 Contractor �ff� t Pi ddrel/ss p City��ZiCrl�ss3 Lic#��Phone/# , 1L� 31 0'0 <br />Consultant/ Sub CMN4,, ,, 1/IrON�"(14&ddress ( ew IPi itygP l' Lic# 53a Phone#_l�(-Q 'Z� <br />GIS Coordinates X 'Y Township ( N Range (✓ Section -� <br />WORK TO BE PERFORMED: <br />b(NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />0 SOIL BORING # <br />'WELL # MIA.) - I Li a. <br />W <br />-Z- <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />*Other:Grout <br />Specifications: <br />FEE INFO <br />COMMENTS <br />CHECK # <br />RE 'D BY <br />(� <br />IT /SERVICE REQUES <br />INVOICE <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />'MONITORING <br />HOLLOW STEM <br />DIA. OF BOREHOLE Srr MULTIPLE CASINGS? 0 MULTI-LEVEL? 0 WELL CASING DIA: <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS SC(t qO TYPE OF CASING: 0 STEEL ;PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE / Ozone 0 PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />0 OTHER: 0 OTHER <br />*COMMENTS: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes if No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS:V�c(?ut cEut & <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( 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 />County Ordinan,6- ",es and Regulations, and all applicable California State Laws. <br />Signed x <br />Print Name <br />Title//C/ommpanny <br />DEPARTMENT USE ONLY <br />2240 <br />SITE MAP IN UNIT IV FILE, ADDRESS: ALe� <br />WORK PLAN DATED: /Z – 22' 03 <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS I CONDITIONS: <br />Date <br />_Date Issued /— Z ! Area O&P/ <br />inal Inspection By 421 Date (0 _-,),D <br />ACCOUNTING ONLY. AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />RE 'D BY <br />DATE <br />IT /SERVICE REQUES <br />INVOICE <br />C-57 ✓ WCC -WAIVER_ C-57 Letter of Authorization to sign permit V-Errcroechment-do — f 8/29/02 <br />