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WELL PERMIT APPLICATION FORM SITE - -- - <br />SAN JOAQUIN COUNTY MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />�r t - t} .03<�-!D \ ` <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 />AMOUNT REM I TED <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br />REC'D BY <br />Assessors <br />WELL Location 4z)0 �%L l� C - 1;HLD�V f;—/ ---Cross Street) �[' ^� ' A< City -,510' � kC-r�,l Zip Parcel#_ <br />PERMIT! SERVICE REQUEST -4 -INVOICE <br />PROPERTY Owner Z?d- SZ -0C �C62.1[r Address S N1l• k 14tQ � City �,V _Zip .5 Phone# <br />C-57 Contractc _ ?4 7 Address„ ., � �' Lf rC t,�' Clty _Zip 9 Z Lic# V �1 U P h o n <br />,r" <br />Consultant / Sub Crntr, 7 t Address._ Cl Bel Lic# (?2 Phcne '(,X% <br />3��� <br />GIS Coordinates: X._ Y _ Township Range Section <br />WORK TO BE PERFORMED: <br />XNEW WELL / BORING (C. -T, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) U DESTRUCTION (choose'ype below) <br />0 SOIL BORING # 0 OVER -BORE <br />WELL # /' 0 PRESSURE GROUT <br />�r <br />� <br />*Other. Grout Specifications: <br />COMMENTS <br />T"� <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />`MONITORING kOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? [I MULTI-LEVEL? tj WELL CASING DIA: -Z <br />4 <br />j] EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS-,%' LL 4' TYPE OF CASING: I] STEEL ;WVC O OTHER: <br />VAPOR a MUD ROTARY DEPTH OF GROUT SEAL �/ < TREMIE TYPE TO BE USED: AUGERS a HOSE <br />Q AIR SPARGE / Ozone 0 PUSH POINT GROUT SEAL PUMPED: Q Yes g'No (NOTE: MAXIMUM FR E-F/ALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: /Ir� �� e -,L .amu T Y� I / & e)__ <br />OTHER: p OTHER APPROX BORING DEPTH 5 S _ OLTED TRAFFIC BOX or U S T OVE PIPE <br />CONDU CTCR CASING PROPOSED? YJ0 (if YES, list specifications here): <br />/ <br />*COMMENTS: 1,1� f� / %$ �'�t5 t ��1'l��c i+3 ! 0 c r`:< 1 • :i f �:�N `_� <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 />1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />Cou Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x 1 Title/Company °�O 01 <br />Print Name_ 1°1 1 a Vu 10 Ct C Date �10 3 <br />DEPARTMENT USE ONLY <br />r <br />SITE MAP IN UNIT IV FILE, AD RES <br />WORK PLAN DATED: L I SI b <br />Application Accepted By // Date Issued I 3103 Area_q_ <br />Grout Inspection By Date_/e) Final Inspection By Date 1 <br />Destruction Inspection By Date <br />COMMENTS / CONDMONS: <br />ACCOUNTING ONLY. AID# <br />�r t - t} .03<�-!D \ ` <br />PE CODES FEE INFO <br />AMOUNT REM I TED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT! SERVICE REQUEST -4 -INVOICE <br />/0/6 D3 <br />3��� <br />C-57 WC -2 WAIVEP, C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02 <br />