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Application Acrpted By
<br />Grout Inspection By
<br />Destruction Inspection By Date
<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 />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 />WELL Location 4?; 114 3ctei-i- 11-ye: Cross Street Lidit, .f; City 5kle.--4.4C-Ci Zip
<br />PROPERTY Owner .....,iCiii. In lc Address /6)S- W \Silva n 9-: e _.. aty 1 1 telfAck4 A izp_24zaphone#(2Z) 4 4 7 -WC.4.
<br />1;32 0 avec C r. c Le - cityatglz. zip9C/42 7 i id Lic# , , , - i C., Phone/&? C-57 Contractor6'05cads .Drillip 3,c, Address 6-?13 4/49
<br />Consultant / Sub Cntr:444,fle_e_AO 4.1 CAA/ Address 837Q.3 ed City_ek lod Lic#6p1.227 7 -t00 Phone
<br />Assessors
<br />Parcel#
<br />GIS Coordinates: X , Y , Township Range Section
<br />WORK TO BE PERFORMED:
<br />ANEW WELL! BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) \1...1
<br />StSOIL BORING # 0 OVER-BORE
<br />kWELL # 0 PRESSURE GROUT
<br />*Other: Grout Specifications:
<br />COMMENTS
<br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS
<br />W.MONITORING X-IOLLOW STEM CIA. OF BOREHOLER X" MULTIPLE CASINGS'? 0 MULTI-LEVEL? a WELL CASING
<br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS s'el,i_ l'e, TYPE OF CASING: [I STEEL XPVC 0 OTHER:
<br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL // - SC' TREMIE TYPE TO BE USED: XAUGERS 0 HOSE
<br />0 AIR SPARGE / Ozone 0 PUSH POINT GROUT SEAL PUMPED: ,jyres a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30')
<br />*SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: if,e)r f-btd ce4---t,4- 94-i/ -/r) (zsa i NI e,
<br />0 OTHER: .11 OTHER APPROX. BORING DEPTH ...:?C---1-.0 ' AVOLTED TRAFFIC BOX or ['STOVE PIPE
<br />, CONDUCTOR CASING PROPOSED? 41 C..) ( if YES, list specifications here):
<br />L..i.At- i Is e, v s / ke --;: t-i_ie c.c,t i; c )--, ,,,, h.,: .1- e o scl (4; i< et 4_1:
<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 />Coun Ordinances, Rules and Repulations, arid all applicable California State Laws.
<br />Signed x ..,,"{----<---k---------"L\__ Title/Company
<br />, .
<br />) Dolt .--> f / Adt-4"c--Q-d 61
<br />Print Name O, n i e I I,KG., vv\lock.c 1,\ Date 91 b I 0 3
<br />DEPARTMENT USE ONLY
<br />16
<br />SITE MAP IN UNIT IV FILE, AITRES:_ t+33 (K) 1 3 C-64-4 5-1-bc
<br />WORK PLAN DATED: 4 1 0
<br />
<br />I
<br />*COMMENTS: i
<br />Area
<br />Date
<br />Date Issued
<br />Final Inspection By
<br />COMMENTS I CONDITIONS:
<br />ACCOUNTING ONLY: AID#
<br />--.
<br />..._e:-)-1-<
<br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE 13 PvirF RFOU INVOICE
<br />3,50 ( -3t1 -if I ,v6,/b3 3 5 5--g.5
<br />C-57 WC -WAIVER 8/29/02 C-57 Letter of Authorization to sign permit Encroachment doc
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