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WELL PERMIT APPLICATION FORM SITE <br />r <br />F 11 V I�C) SAN JOAQUIN COUNTY MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />JAN 2 6 2004 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />EWHUNMENT HEALTH (209) 468-3449 <br />ORIGINAI- <br />PF-RMIT/SERVICES 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 9-1Q115.3 and the Standards of San Joaquin County Environmental Health Department. <br />l 1 QAC City Zip 1t✓37�o Parcel# Assessor's � 12 2 U0 0 8 <br />WELL Location ` ' r Cross Street p� ' l -I <br />PROPERTY Own11e,,,rlI..►q�' IrT(((aV;S,pptr"!Ut`bAlytG, Ad/drress 3 rM Ir_ hIII�Dyhjh _ �Ct�R1 -city CWK0 Zip gt7(D Phone# 90 �J17—X115 � <br />C-57 Contractor WWF2 t)dq,V4 Address (otDO e6a6OOI CCityQ.%ba5io Zip 15473 Lic# 1774W Phone# 7�\� X1-'3 .4 D"T <br />Consultant / Sub Contractor BIo�c1t, 111,1., IVP4 Address d ICA. City P6164 Lic# Phone# <br />GIS Coordinates: X Y I ownshio Range Section <br />WORK TO BE PERFORMED: N' <br />EW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) DESTRUCTION (choose type below) <br />0 SOIL BORING # D OVER -BORE <br />�GVELL # MW -t$, (�, -ff �o 0 PRESSURE GROUT -G <br />'Other: , Grout Specifications: <br />COMMENTS: r) <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING 'HOLLOW STEM DIA. OF BOREHOLE SMULTIPLE CASINGS? DYES YNO WELL CASING DIA: <br />p EXTRACTION H AIR HAMMER/DRIVEN CASING THICKNESSSelt.4Q T/ PE OF CASING: 0 STEEL PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 0—M TREMIE TYPE TO BE USED:AUGERS 0 HOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: D Yes 0 No (NOTE: MAXIMUMFREE- ALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: '501- SeYdbvb1 . P rf'ft'l CA%" . r,i1a,4r <br />0 OTHER: [I OTHER APPROX. BORING DEPTH BOLTED TRAFFIC BOX or 0 STOA PIPE ) <br />CONDUCTOR CASING PROPOSED?if YES, list specifications here): <br />'COMMENTS: <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 Joaniain <br />County Ordinal s, Rules an egulations, and all applicable California State Laws. <br />VV <br />Signed x Title/Company L 1441V 5C �V' In,,- <br />� 1 <br />Print Name fT!►'� V 6I!ftla Date_ <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 42.5- L_41 -CA R0 ,114c <br />WORK PLAN DATED: C+o 10.0'� 9 2100 3 <br />Application Accepted By i Date Issued J ), Area <br />Grout Inspection By VIGtor."'t L Y&4# Date 112Z28 ) Final Inspection By ice r <br />Destruction Inspection By Date ,1 T <br />COMMENTS /CONDITIONS: tri f � i csy, of -4 mon;+'e� Ldc�gf —YnW -1s m�y /G mw-17.mw18 <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATEPERMIT / SERVICE # <br />INVOICE <br />iso <br />gg. ao <br />�9. o� <br />sR# DD 3G 7z -' <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_ Encroac�doc 1/25/02 <br />