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ORIGINAL <br />WELL PERMIT APPLICATION FORM SITE <br />MITIGATION <br />UNIT <br />SAN JOAQUIN COUNTY UNIT IV <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 V / V <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 off San Joaquin County Environmental Health Department. Assessor's 123 1 V 0/ <br />1 f! 76 (fet,� 44 AKd Cross Street /i x".0h City Zip f�� Parcel# 9� <br />WELL Location � �. <br />PROPERTY Owner <br />/ / / <br />J ��, Ay S eZ- Address 103 �. 440/M1,/_ city S1'ar-44oi Zipff.20)Phone# X09 <br />/ ? ��S l-�iyc�.oh�► >)A• City �7� `rZipic# 's/LZ Phone# 29Q �S k7/2 <br />C-57 Contractor SI�ecT'hirl t dress� <br />/�� E�io/f�ea CityGltz�./IG>16Cic# sl 38's7Phone# 70 �685`�06 <br />Consultant Address <br />GIS Coordinates: X <br />WIA'Op?. 393 ' . Y N dyq /, Township _/ N Range 6 Section <br />WORK TO BE PERFORMED: XbESTRUCTION (choose type below) <br />%PEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') COVER -BORE <br />%P <br />_ 0 SOIL BORINQ # a PRESSURE GROUT <br />J NVELL # 1"Z _T L .2 Z Z <br />Grout Specifications. <br />'Other: Ord V oic <br />COMMENTS: 01W kk,.,c <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE T ACA MULTIPLE CASINGS? 0 YES NO WELL CASING DIA: / <br />MONITORING <br /><HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS Srh TYPE OF CASING: 0 STEEL VC 0 OTHER: <br />f�U <br />0 EXTRACTION <br />DEPTH OF GROUT SEAL Arf Q'+O*A V+ l"REMIE TYPE TO BE USED: 0 AUGERS )0­I0SE <br />R <br />0 VAPOR <br />0 MUD ROTARY <br />GROUT SEAL PUMPED: Nyes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />0 AIR SPARGE <br />0 PUSH POINT <br />��� <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS:f <br />APPROX. BORING DEPTH C -WO+ 02-I 'OOLTED TRAFFIC BOX or 0 STOVE PIPE <br />� <br />0 OTHER:_O <br />OTHER <br />OSEDv�_ ( if YES list specifications here): <br />CONDUCTOR CASING PROP <br />/�Z / //'�Z %/'i T4�ii/ ,G pAti /8' �; � � �6. ( il`, s�� cc ,!Q 12. r4-"' <br />'COMMENTS: 102 <br />?t f , ,G. SL/ <br />2 l 2 <br />rinTF• nFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL RE;UUINtu Ilvarr� ��•�• <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />Count;0/— <br />les and Regulations, and all applicable California State Laws.. u `� <br />Title/Company v x' <br />Signed x <br />��![.G/,! atePrint NameDEPARTMENT USE ONLY <br />LE ADDRESS' <br />SITE MAP IN UNIT IV FI <br />WORK PLAN DATED: �o ' <br />Application Accepted By_ <br />Grout Inspection By <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />welpim— <br />Date Issued ' 3 Z� Area �v 0 <br />Date <br />Date Final Inspection By—tel <br />Date <br />rent <br />PE CODES 4FEEFO AMOUNT REMITTED CHECK # RECD BY DATEC-57 _ -WAIVER C-57 Letter of Authorization to sign permit <br /># I INVOICE <br />1/25/0 <br />