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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 />(209) 468-3449 <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br /> <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 of San Joaquin County Environmental Health Department. <br />Assessor's <br />WELL Location tot) 14).1.412.1us+C,u-ve_ 2r3 Cross Street 14,...s 5 City -Dtmk.kAl.r...-) Zip Parcel# <br />PROPERTY OwnerBal 4141 Ca? Address‘2C6 61-c:olei4i S-104 ea City ,c-jrx.1,4tA,_ Zip9SZtei Phone# <br />C-57 Contractor Vi IAJ Address 100S44ft 54C-C.2..4— Citylk(4J4T.A, Zipq5/041 Lic# Thibel Phone#qii, 111 tA IOC) <br />Consultant/Sub Contractor (xertriod 2err) Addressillq Ytottim. Skei2..+- Cityesepl..... Lic# Phone#zoct 83t cant <br />GIS Coordinates: X <br /> <br /> , Township 4A—( Range SE_ <br /> <br />Section <br /> <br />WORK-TO-BET E R FOR M E D: <br />,NEW WELL) BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />a SOIL BORING # 0 OVER-BORE <br />XVVELL # YAW ., nttA.) L. ) Ku..., 1 0 PRESSURE GROUT <br />*Other. Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />)KNIONITORING XHOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />0 SOIL BORING B HAND AUGER <br />0 OTHER: a OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE S346S, MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: 2 ' w-A^ <br />CASING THICKNESS 5c/A 40 TYPE OF CASING: 13 STEEL )(PVC 13 OTHER: <br />DEPTH OF GROUT SEAL 1 TREMIE TYPE TO BE USED: a AUGERS 0 HOSE <br />GROUT SEAL PUMPED: U Yes po (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') cp <br />GROUT SPECIFICATIONS: effNereke <br />APPROX. BORING DEPTH iq ce.e.,4- )(BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING CASING PROPOSED? ( if YES, list specifications here): <br />e.e441.Wili c4.44r-its-i5 bad vioxiiie *COMMENTS: bud) 64. v.e /Ai <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 />Signed x <br />Print Name <br />I hereby certi <br />County Ord" <br />th ye prepared this application and that the work will be done in accordance with San Joaquin <br />les and Regujati6ñs, and all applicable California State Laws. <br />Title/Company SAW,' 624/45/St <br />Date Sn?-}844A ivy 2cm) a_ (-crve_j <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br /> <br />Date <br />Date Issued Final7/3-7-St(i— <br />Inspection By a <br />Date <br />r <br /> <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: CNN_ <7 tlt <br /> <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE P IiViut EST # <br />c0( SC1— F Cr- OLETI1 (-:11/V-- <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit ment doc <br /> <br />1/25/02 <br />