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a <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />-71625 141/ Pi e IQ L, c. (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 01 <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location a t <br /> J <br />e <br />- <br />i' <br />06M <br />f <br />- <br />., <br />2 <br />,, <br />4 <br />' _ <br />'1 <br />, <br /> 11-0 Cr S treet 4461-1A,L <br />. <br /> City--1'0.C4—hk ZipS26.._, P <br />A <br />a <br />s <br />r <br />s <br />ce <br />s <br />l# <br />or's ...„. <br />- <br />, <br />4 <br />. <br />- <br />.). <br />PROPERTY Owner e I 4-4( rie ) Address .5-2.Cz- bA/.41,5tity,5-7 4,811 Z119,52/)5P h on e# <br />C-57 ContractoRrVgi 61S-ric, Address/50 HAiltpe R-12._ City5:4,16(01Zip3Licif6174167PhYnif 3)3 6-eraD 31 <br />Address2-179 c5A41 k) P--c:e City ylLic# Phone#A ,H g6 7 larfr c > Consultant / Sub Cntr A66-- <br />GIS Coordinates: X Y , Township Range Section <br />SITE <br />MITIGATION <br />UNIT IV <br />WORK TO BE PERFORMED: <br />.,8-1qEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) fl DESTRUCTION (choose type below) <br />rb-cc) i L. BORING # l] OVER-BORE <br />13 WELL # a PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE <br />MONITORING HOLLOW STEM <br />O EXTRACTION U AIR HAMMER/DRIVEN <br />VAPOR f] MUD ROTARY <br />AIR SPARGE / OZOneRPUSH POINT <br />80IL BORING a HAND AUGER <br />OTHER: 13 OTHER <br />*COMMENTS: Co' I 2 '1i7 r <br />CONSTRUCTION SPECIFICATIONS/ <br />DIA. OF BOREHOLE l•D OfTIPtE CASINGS? a MULTI-LEVEL? U WELL CASING DIA: <br />CASING THICKNESS A14- TYPE OF CASING: STEEL flPVC U OTHER: <br />DEPTH OF GROUT SEAL eiTy4.6 TREMIE TYPE TO BE USED: U AUGERS a HOSE <br />GROUT SEAL PUMPED: j],Yes fi No (LOTE: MAXIMUM FREE -FALL DEPTH IS 30' <br />GROUT SPECIFICATIONS: PothAn <br />APPROX. BORING DEPTH / gl ) Fee+ I] BOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />12,0) 6)01 C/ <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. <br />b_. <br />Signed x IA/ Title/Company <br />Date Print Name W;71114-1.- <br /> <br />DEPARTMENT USE ONLY <br /> <br />SITE MAP IN UNIT IV FILE, ADDRESS: 31-8 1--(A.v) 01, ) al-46(44/7 <br />WORK PLAN DATED: /-71- <br />Application Accepted By <br />Grout Inspection By Date <br />Destruction Inspection By Date <br /> <br />Date Issued Area <br />Final Inspection By Date <br /> <br />COMMENTS / CONDITIONS <br />ACCOUNTING ONLY: AID# - <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE li,...E_BMIT-f-ErERVICE-BE OIL # INVOICE <br />( S'RPO3 i 9.7 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br /> <br />8/29/02 <br /> <br />I <br /> <br />I • <br />