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GRIGMa <br />WELL PERMIT APPLICATION FORM SITE <br />MITIGATION <br />SAN JOAQUIN COUNTY MMUNIT--1W <br />1 1 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />r <br />304 E. Weber, Third Floor, Stockton, CA., 95202 JAN 0 03 <br />(209) 468-3449 0tj <br />"" Vv p <br />-NVIROi�lN1�f�; F-itr�lL i <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 <br />/the Standards of San Joaquin County En/viro/nm/ental Health Department. Assessor's <br />'0 7�j �y u�p�W Cross Street n%ff/on City �7r�YY�'► Zip ?,F2-62 Parcel# 1L3`/9/'�/ <br />WELL Location / G <br />PROPERTY Owner &2%/ %'e2 Address fro 3 66& <br />&x -t- k City j -/..Ci ti Zip 7 203 Phone# ,� �/ � /'Z <br />S �n Y,O� Address 23 6S�Lyisiu� �` City S7wx (rk' Zip '�Lic#S/�� Phone#2� /IL <br />C-57 Contractor�,t�Et- <br />Consultant /Sub Contractor ��9 AddressCitY �"""'-��ic# S13�r� Phone# <br />�y� /(,'.? �'S� aY'r ,Township llV Range 6 E _--Section <br />GIS Coordinates: Xwll�/Q Y <br />WORK TO BE PERFORMED:DESTRUCTION (cho e type below) <br />0 NEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') ER -BORE <br />0 SOIL BORING # [LPRESSURIJE�E GROUT <br />0 W ELL #t S 'f tions All � � � ��'T of <br />`Other: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />HOLLOW STEM <br />Grou pea iaa <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES ONO WELL CASING DIA: -N <br />0 MONITORING U0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL E PVC 0 OTHER: <br />D l] <br />VAPOR MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30')� <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH 33+ D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER:_O OTHER_ Al <br />CONDUCTOR CASING PROPO ED? ( 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 Joaquin <br />County Ordinances, -Rules and Regulations, and all applicable California State Laws. C -t' � `w - 4� <br />Signed <br />a <br />Print Na <br />SITE MAP IN UNIT IV FILE, ADDRESS:_ <br />WORK PLAN DATED: /®-15 -Q 7-- <br />Application <br />i <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Inspectio <br />COMMENTS / CONDITION <br />Title/Company (/ )v GN- '02 <br />DEPARTMENT USE ONLY <br />i <br />Date <br />inal Inspection <br />ate 1A - /�P- 02- <br />-�iiY_.1 <br />0 Os <br />ACCOUNTING ONLY: AID# r:Ar`+ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # RE 'D BY EDATE P <br />REQUEST # INVOICE <br />' 32- " ��� s # <br />3�i�� LAJ-b .v '- 1/25/02 <br />C-57 WC ✓ -WAIVER_ C-57 Letter of Authorization to sign permit oachment doc <br />