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WELL PERMIT APPLICATION FORivi <br />FER - D 200Z <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />ENV . NT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />PL... 1 I SERVICES (209) 468-3449 <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 Joaquin County <br />Development Title, Chapter 9-1115.3 and the Standardsf San Joaquin County Environmental Health Department. <br />WELL Location c3 L1 01 LAR5-k-- iorrerg- •Cross Street .44.11-- City LP) 1 <br />) <br />s6V-s66's Zip 9f>179- Parcel# <br />PROPERTY Owner A,16e... 0.00(c,c,,,,-, Address )-CIG (A..), 1-6"01/./I> City C))1 Zip Cico)qPhone# 6. V V -6 <br />C-57 Contractor G k--e 5 Pr! lit, Address 950 hti ,..)e /6.4)e ci zip9'tl3-3Lic# 656 '4,'Zne# (9.2-5-) 3/ 3 -3-ece <br />A g 1 51,,a„, City cjeCiekic# gdo1,2? Phone# Vi6 7-1e266 G-F Address Consultant / Sub Contractor <br />GIS Coordinates: X , Y , Township <br /> <br />Range Section <br /> <br />WORK TO BE PERFORMED: <br />**KEW WELL / BORING ( CPT, GEOPROBE, HYDROPOCH, HAN9-AUGER, OTHER') 9 DESTRUCTION (choose type below) <br />OIL BORING # 1 (/ f)y 9 OVER-BORE <br />9 WELL # 9 PRESSURE GROUT <br />*Other:0 5 i+e Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL <br />9 MONITORING <br />9 EXTRACTION <br />O VAPOR <br />O AIR SPARGE <br />OIL BORING <br />OTHER: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />[I HOLLOW STEM DIA. OF BOREHOLE c)-1 MULTIPLE CASINGS? 9 YESN WELL CASING DI/k4-?4.- <br />0 AIR HAMMER/DRIVEN CASING THICKNESS AM , TYPE OF CASING: 9 STEEL 9 PVC a OTHER: <br />9 MUD ROTARY DEPTH OF GROUT SEAL EiritThq, TREMIE TYPE TO BE USED: 0 AUGERS rOSE <br />>t(DUSH POINT GROUT SEAL PUMPED:) (es 9 No . (NOTE: MAXIMUM /FREE-FALL DEPTH IS 30') <br />0 HAND AUGER GROUT SPECIFICATIONS: gitai i ig 5adc ferf(q•krY N,1- 6 7q (7or-5 C,,-, clie'— <br />r1 OTHER APPROX. BORING DEPTH 15---/S"--) 0 B LT D TRAFFIC BOX or a STOVE PIPE <br /> <br />CONDUCTOR CASING PROPOSED? if YES, list specifications here): <br />*COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />SITE <br />MITIGATION <br />UNIT IV <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 Re ulations, a‘p II applicable California State Laws. <br />[Ft), <br /> <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 08 Avr)s-fr -200 / <br />Application Accepted By /, <br />Date <br />COMMENTS! CONDITIONS: <br />Signed x <br />Print Name <br />A . <br />Gun ' <br />6e,I01() /4- ./ <br />Date c721 D/012' <br />DEPARTMENT USE ONLY <br />Title/Company <br />FEB 1 5 LIOZ <br />ENVIRONMEN EALTH <br />P IT/SEk <br />Date Issued <br />Grout Inspection By /4 KA,"0-'4" Date )(I ti .2- Final Inspection By <br />Destruction Inspection By Date <br />Z.--Of? OCV Area • <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT /SEEiJt# INVOICE <br />/4-I'L 1---// ? /XSR#C3 0,2g 2-0 <br />C-57 <br /> <br />WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit \EizErs____•oiachment doc /25/02