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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 />-f �5 '/,) / y -4 n r-- �I Assessor's <br />WELL Location / Yfy i� 4 Cross Street 1nn e Ls" City Zip`/_Parcjell#) <br />PROPERTY Owner ✓ ��► N (/�/11L� Address b�'� �l / 1( City L Zip G1 P6ircone# �6?S /86L <br />C-57 Contractor WC1J(J(,lJ4 "Jt7ddress 33(41 l City I0V� r71Zip��s//Li,# "7`DD. I Pho��%#7 3 ��- �3v� <br />Consultant / Sub Cntr �� Addres4f12, �Ii G'�%' l� City -_<4 ic# Phone# <br />GIS Coordinates: X <br />WORK TO BE PERFORMED: <br />0 NEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH <br />0 SOIL BORING # <br />0 WELL # <br />*Other: <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE <br />2 -MONITORING gHOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />�APOR 0 MUD ROTARY <br />0 AIR SPARGE / Ozone 0 PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />0 OTHER: 0 OTHER <br />Township <br />HAND -AUGER, OTHER*) <br />Grout Specifications: <br />Range Section <br />STRUCTION (choose type below) <br />VER -BORE <br />,WRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS ,"kl U le G4 Q <br />' �� <br />DIA. OF BOREHOLE/L /�< ULTIPLE CASINGS?MULTI-LEVEL? WELL CASING DIA <br />CASING THICKNESS TYPE OF CASING: 0 STEEL /01�`VC 0 OTHER: <br />DEPTH OF GROUT EAt y� TREMIE TYPE TO BE USED: AUGERS 0 HO Es <br />GROUT SEAL PUMPED: ,eYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />GROUT SPECIFICATIONS: n84P."I" ;,,�L �1_ " <br />APPROX. BORING DEPTH I Pd 4-4e-4- Z-9OLTED TRAFFIC BOX or 0 STOVE PIPE <br />CON UCTOR CASING PROPOSED? if YES, list specifications here): <br />*COMMENTS: L"YJ� -� �J�l lei �C � (J_5 �� ril , Dl -e e i l l W z�� � MW; IOW 3 MILI L <br />\/�o,o-- Is VW <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 />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. % (1� <br />Signed x li" t/d.�'Lyv �- Title/Company E_ (-"7i--£] ,/ J rJ i <br />Print Name w' A a-, "� t � �� Date /? O? `2 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: L L',-i� ra <br />WORK PLAN DATED: / I1" O 3— <br />Application Accepted By <br />Grout Inspection By_ <br />Destruction Inspection B <br />COMMENTS/CON <br />Date Issued 1,2-11,2,16 Area <br />Date G a Y Final Inspection By "wti Date -3 <br />Date <br />4- Z d' d 'y V W/ V t' i <br />ACCOUNTING ONLY: AID#(;;Tl'� 1� <br />PECODES <br />FEE INFO AMOUNT REMI ED <br />CHECK # <br />REC'D BY <br />DATE <br />INVOICE <br />TSnWCE-RE=ST # <br />j0 <br />0 J7 2� <br />IZ av <br />a I (p 2 <br />C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ 8/29/02 <br />