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.� WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />Vv (209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED O <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 Joaquin County <br />Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />C- Assessor's <br />WELL Location J5 S - �u'K tL K��. Cross Streaelt T � City S i )CV -76&1 Zipfs Parcel# Oil Z --24-),- Com/ ] (/ <br />PROPERTY Owner LU 5 C_(r LLLII Al ( Address_ I- kt0Ett4(ZiDiu& (j- city v�� Zip Phone# <br />C-57 ContractorWOplti,gb �L"r-I(FAddress SSy IZ/00% Cp_ ' I City i AOS f%) Zip/��,]// Lic#7Phone#-( � -7) �7`�- .340 <br />Consultant /Sub Contractor A � r��b E�11/i �'d. Address -931 �{ � l CilyS7`J /tY�Lic#.�, �IIL' Phone# Z09 )4k 7-/Lv 6 <br />GIS Coordinates: X <br />Y <br />Township Range Section <br />FAC# <br />WORK TO BE PERFORMED: <br />/jam <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) t DESTRUCTION (choose typ ole <br />OVER -BOR <br />0 50i6�RING # �0 <br />`(^3 <br />PE CODES <br />0 WELL #QCT <br />/ 1 <br />— J <br />'Other: <br />_ _-- <br />+� <br />Grout Specifications: <br />COMMENTS:'Pt f, c—c)C <br />1 4 t sSwCL <br />Tre"-r (jn1c- ►LLJr�I/TuL'lAllr LtJ>r LL <br />( , <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS ,/ n <br />�II <br />�IVIONITORINGIOLLOW <br />STEM <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES NO WELL CASING DIA: 7` <br />ELL <br />` I 1 <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS r V TYPE OF CASING: Q ST a PVC 0 OTHER:_ <br />(W <br />v 1 <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE <br />p PUSH POINT <br />GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />n <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATI NS: <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <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 County Ordinances, <br />Rules and f egulations and_all ap 1icable California State Laws. <br />Signed x C L� Title/Company i�! /� L (lCct d�r j �LEV C {�C L it�Gi rL'iiV fttEnl SAL <br />Print Name_ AI), L ?> ��D! t,_/ Date—d7 Z16 <br />Z <br />C� DEPARTMENT USE/ONLY <br />-SITE MAP IN UNIT IV FILE, ADDRESS: 35.3 v • C� K eC�� /�/v �LO� ' <br />WORK PLAN DATED: O -z— <br />Application <br />Application Accepted By Date Issued 7- Area <br />Grout Inspection ByDate %" �a' 0 �' Final Inspection By a' D 7- 30-02-- <br />Destruction Inspection By Date %• 30'O — <br />COMMENTS / CONDITIONS: It <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PE SE-.. INVOICE <br />3E;0 2-. <br />sR# <br />C-57-)4- WCC -WAIVER_ C-57 Letter of Authorization to sign permit_ Ericroaattmeni daI775—/02 <br />