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<br /> <br />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 /> <br />SITE <br />MITIGATION <br />UNIT IV <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 Port R..<1 I LI- Cross Street CT City Stocktor Zip 95203 parcel# ( 45-030- 0 I <br />PROPERTY Owner Fort of Stock+ori, Address P.O. BOX -Z°89 City 5+0c_k -toi1 Zip 95201 Phone# 109 —9 +6—o.24(;) <br />C-57 ContractorTre cTtn Sampli151,4kidress (1-1-00 S. S+, City RI ,noAd Zip14204 Lic#6563S7Phone# 510-J31-4,51S <br />Consultant/ Sub Cntr CTeornatriA (.onsR IhniciAddress al+44- kitin fC.JS City Fr'sn° <br />GIS Coordinates: X , Township I N.) Range 6 E Section <br />WORK TO BE PEFFORMED: <br />KNEW WELL / ORIN9 CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") • i trect rusk) DESTRUCTION (choose type below) <br />0 SOIL BORING # to cecbTO(tS (CluoL_Q h°p c 0 OVER-BORE <br />0 WELL # PRESSURE GROUT <br />*Other: Grout Specifications: need- Cenleyff rwAt -(-or' botl-am (kr <br />COMMENTS <br />Lic# 6 S 3 3 65 phone# 5594-1535 <br />TYPE OF WELL INSTALLATION TYPE <br />MONITORING fl HOLLOW STEM <br />0 EXTRACTION AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE gPUSH POINT <br />'SOIL BORING 0 HAND AUGER <br />0 OTHER: U OTHER <br />`COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 10" MULTIPLE CASINGS? 0 YES MVO <br />CASING THICKNESS TYPE OF CASING: U STEEL 0 PVC U OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br />WELL CASING DIA: <br />GROUT SEAL PUMPED: g Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30't)._ <br />GROUT SPECIFICATIONS: flat- cewte-n±. j rota <br />APPROX. BORING DEPTH SO' 0 BOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <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 />Signed x ly(A/V1 611 <br />4T -61.e cjeovt. <br /> <br />0,(01,,+ 6,0mairi.c Title/Company , Enov'ln:e0; 03 <br />Date <br /> <br />Print Name <br /> <br />DEPARTMENT USE ONLY <br /> <br />SITE MAP IN UNIT IV FILE, ADDRESS: ,41-41 /e-a /3 f /(.( <br />WORK PLAN DATED: /6 -2- — <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br /> <br />Date Issued <br /> <br />Area 4 <br />ate <br /> <br />Date <br />Date <br /> <br />Final Inspection By CO <br />411111111117//, <br /> <br />63 <br /> <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE P SERVICE <br />C-57 V WC -WAIVER 1/25/02 C-57 Letter of Authorization to sign permi