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WELL -PERMIT APPLICATION FIRM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />SITE <br />MITIGATION <br />UNIT IV <br />(209) 468-3449 <br />PE CODES <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />AMOUNT REMITTED <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 />DATEMIT / SERVICE REQUEST # <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessor's/ <br />x _- II ' ,+ ' / <br />%>> �� �iw �i / `/ �'Cy� <br />WELL Location W /,�( Cross Street cnL City's%,.,e*— Zip Parcel# <br />PROPERTY Owner(�S S G�<�L %/c, / Address (G�7� ���f C (�}% CitvS� d6kr,%/ Zip Phone# 06 - C)�6 z <br />l ���/�y�l <br />C-57 Contractor M r rGy(/.c�- Af[,(../ dress_S36,& ` w14 r7' 611 A1C. City S4)C Zip Lic#6/4(/7 Phone l,- <br />Consultant/ Sub Cntr 14 � Address / �- SI�nL✓ City C1CL' j Lic# G� 217 Phone# <br />GIS Coordinates: X Y Township Range Section _ <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE <br />0 WELL # 0 PRESSURE GROUT <br />'Other: Grout Specifications: <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />r <br />MONITORING `HOLLOW STEM DIA. OF BOREHOLE` MULTIPLE CASINGS? 0 MULTI-LEVEL? 0 WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS:::�h{ qO TYPE OF CASING: 0 STEEL iLPVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL(, vI,C S TREMIE TYPE TO BE USED: [}AUGERS 0 HOSE <br />(� <br />0 AIR SPARGE / Ozone 0 PUSH POINT GROUT SEAL PUMPED: kkYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: T �7 LAAJP rc <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 35 f r 76B LTED TRAFFIC BOX or 0 STOVE PIPE <br />c, <br />CONDO OR CASING PROPOSED? & O (if YES, list specifications In e): <br />y` <br />"COMMENTS: �1.�� (`f ltc ., S� S / ��r d / <br />(LLS <br />NOT OFFSI• E 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 prepar this application and that the work will be done in accordance with San Joaquin <br />County Orth7nces,, ules nd u Ions, and all applicable California State Laws. <br />Signed x L// Title/Company <br />KC!k` G�i� ��C-L'y✓tQ� <br />/weGl�0 / iCGt <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection B <br />COMMENTS/ CONDITIONS:-Iz� _`S <br />DEPARTMENT USE ONLY <br />wvYC� 14n A <br />Date <br />_Date Issued_ <br />al Inspection By <br />Area <br />I <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATEMIT / SERVICE REQUEST # <br />VOICE <br />C-57 WC= WAIVER_ C-57 Letter of Autho�` n/ sign perrnii--€rleropehmeh AO—C 8/29/02 <br />