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t SAN JOAQUIN COUNTY SITE <br /> N� <br /> EN tC)N ENTAL HEALTHDEPARTA T <br /> MTATIN <br /> 304 East Weber Avenue,3r Floor, Stockton, CA 95202-2708 "C1NIT IV <br />:I (209)468-3449 Fax:(209)468-3433■'Web:www.co.san-joaquin­ca.us/ehd =- <br /> WELL PERMIT APPLICATION FORM <br /> t+l+t?N-REFUNDAIBLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 <br /> Appliration,'ts hereby made to San.Joaquin County fora permit to construct and/or install the work described. This application is trade i6icomipliance with San <br /> Joaquin County Develop rnenCTitle,Chapter 971145.3 and the Standards of San Joaquin County Environmental Health Department <br /> Asso rs. <br /> WELL Location 24 >t3.::H Nwy 95 Cross:Street�7"glt 9►tf Fc d. City A 11 "t pti Zip <br /> _ arcei# <br /> PROPERTY Owner 8,1 C4;i.f 0 5 f4 4adifress.P.01 b 0z 14 3 S Oily. Ludt` Zip $2 Pro # 9 a 33=z9 <br /> C-57 Contractor.r�'li:#C I�Q I�rt�l:t y Address I:O�i,�i3 M t 14'L Z O tittr try City ti~ Zipiac# <br /> Consultant 1 Suta:Cntr 94%14,40: EIIV. . Address ,I3 C x $ 9` _-City.MUHtf4e Lie# S$5 Phone# F I6 3 S Q <br /> I° <br /> GIS Coordinates X. ,Y. Township Range. Sec n t <br /> WORK TO BE PERFORMED: <br /> i a NEW WELL 1 BORING(CP`T riEQPROSE MYDRQP..NCH,HAND-AUGER,OTHER-) I DESTRUCTION(choose4kbelow) <br /> [1 SOIL BORING 4 OVER-BORE—DIAMETER <br /> y <br /> .. riVELL J,PRESSUIRE GRCI IT <br /> WOther: Grout Specifications: hl <br /> f <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS � <br /> [I MONITORING Q HOLLOW STEM DIA.OF BOREHOLE _ MULTIPLE CASINGS?(I YES a NO WELL CASING DIA: <br /> 11 EXTRACTION :0 AIR HAMMERIDRIVEN CASING THICKNESS TYRE OF CASING: Q STEEL. Q PVC;:p OTHER. <br /> a VAPOR: MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE;USED: I]AUGERS [I HOSE <br /> p AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') 1 <br /> G SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> Q OTHER: 1]OTHER APPROX.BORING DEPTH i1 BOLTED TRAFFIC BOX STOVE PIPE <br /> t: <br /> CONDUCTOR CASING PROPOSED? (i#YES,list specifications here): <br /> *COMMENTS. utsty`ay k`( preis t"em ( oh-1;46 m �I�Idoto 3ls wflis <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PEkMIT& I. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION& I <br /> Ihereby>certify than 1 have prepared this application and that the work will be done in-accordance with San Joaquin <br /> County C>rdinances,Rules and Regulations, and all applicable California State Laws., 41 <br /> Signed x Ir.1 + n.ri...►^�' �.. TitlelCompar+y `fJ :fit( R h o <br /> _ <br /> -- <br /> Print Name' # 4 "fv►l: }' ... _. _. . . _ <br /> e• <br /> .� Qate I7 �- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS::. <br /> .. <br /> WORK PLAN D..ATE© . ` <br /> f3 Area <br /> a <br /> Application Accepted By Date Issued x <br /> Grout Inspection By 111' Date " Final inspection By <br /> Destruction inspection By Date <br /> COMMENTS t CONDITIONS; tmk At 9) ; Ae - r, <br /> FAC# <br /> ACCOUNTING ONLY:: P:ID# - <br /> PE CODES FEE.INt G1 AMOUNT REMITTED GHEGtC# REG*D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57 WC =WAIVER e-57 Letter of Authorization to sign permit Encroachment <br /> W.ELL PERMIT SITE <br /> EHD 29-02-000 <br /> $727/20413 <br /> - <br /> ti <br />