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<br />ORIGINAL <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 />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 />Assessors n /0.45-0•52. Parcel* <br />Address ,...?e-c) Zi Cit Owner <br />PROPER1j4/4.40 14,14SeN, <br />- Zip C lone# 55g-- X.32-a)- <br /> <br />C-57 Contractor Crlki i City Itres, zipq22 1 Lic04•227 Phone# el(o -)0(.1,0 Addresser• v•Or ?‘ <br />Consultant / Sub Cntr 4C.,t Address VS7 Citygrr— <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />KNEW WELL I BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,' OTHER*) <br />X.SOIL BORING # <br />a WELL # <br />a *Other <br />COMMENTS: <br />a DESTRUCTION (choose type below) <br />El OVER-BORE. DIAMETER <br />U PRESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <br />WELL Location I )+1, St Cross Street EL:4 S. City Zip <br />Lic# W-127 Phone# <br />TYPE OF WELL <br />El MONITORING <br />INSTALLATION TYPE <br />fl HOLLOW STEM <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> <br />O AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br />a MUD ROTARY DEPTH OF GROUT SEAL 2cD TREMIE TYPE TO BE USED: U AUGERS U HOSE <br />OZONE PUSH POINT (GP or CPT)GROUT SEAL PUMPED: fl Yes *Oo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />O HAND AUGER GROUT SPECIFICATIONS 1c*6- <br />U OTHER APPROX. BORING DEPTH 2.0 a BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED It.) 13 (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR.(NSPECTIONS. <br />t I have prepared this application and that the work will be done in accordance with San Joaquin <br />n. ces, Rulestid R ulations, and all applicable California State Laws. <br />Title/Company 441ev.14- Pc) <br />. JI.i Date <br />DEPARTMENT USE ONLY <br />1es. c-1/ SITE MAP IN UNIT IV FILE, ADDRESS: /456/5 50 . 7 oer, /10--47%-4-11r <br />a EXTRACTION <br />VAPOR <br />fl AIR SPARGE/ <br />)kOIL BORING <br />a OTHER: <br />I hereby certify t <br />County Or <br />Signed x A G <br />Print Na <br /> <br />C <br />WORK PLAN DATED: Affril <br />Application Accepted By Date Issued <br />Grout Inspection By <br />Destruction Inspection By <br />Date <br />Date <br /> Area C)46 e5if <br />Final Inspection By -Date z-l-c2-5- <br />- -6 V <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE REQU # <br />360 i ..:"..„..- 8°7 1 4t, <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit chment docA/ 9/30/02 <br />