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WELL PERMIT APPLICATION FORM SITE <br /> y ►4 ,_,; , ; I`! f�L�;l 1SAN JOAQUIN COUNTY - MITIGATION <br /> r'r _ ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> 02 FEB 19 AM 9., 47 (209) 468-3449 <br /> off Goy <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work descnbed 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 7 Z5 E[ De rcJo 7 U'�t Cross Street 1-410J St"-Ct City 5-E00kf0•1 Zip Parcel# <br /> PROPERTY Owner C,-EV0-y 'Uek-- pA Address_Rtikt-0449&-/ city Zip Phone# <br /> C-57 Contractor S CA Address 2 G (ala 4 3,2w City ko -- Zip ZO S Lic# hone#- o o- S_- 71 <br /> C'olww.b.� <br /> ' Consultant/Sub <br /> Contractor P41112 fixr"/Lees AddressLla LJ-St S<KA.-,j C City LL34 Lic# Phone# &j,02,11-164 <br /> ' C' 0 GIS Coordinates X 3") 56 r Y Y 7 -1 1 7� W Township Range �� � _Section /-0 <br /> WORK TO BE PERFORMED <br /> NEW WELL I BORING(CPT,GEOPROBE, HYDROPUNCH .HAND-AUGER,OTHER") 11 DESTRUCTION(choose type below) <br /> ' SOIL BORT- la OVER-BORE <br /> SWELL#jeM+a-4'J a PRESSURE GROUT <br /> "Other Grout Specifications <br /> _COMMENTS l(/ <br /> ' TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING(m,j.+) XHOLLOW STEM DIA OF BOREHOLE LS " MULTIPLE CASINGS?(]YES )<NO WELL CASING DIA <br /> XTRACTION (]AIR HAMMERIDRIVEN CASING THICKNESS 7-"• TYPE OF CASING Q STEEL )<PVC a OTHER <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ;.0 TREMIE TYPE TO BE USED AUGERS 0 HOSE <br /> 1i (I AIR SPARGE XPUSH POINT GROUT SEAL PUMPED p Yes XNo (NOTE' MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING(Pit) I]HAND AUGER GROUT SPECIFICATIONS_ C .rf Q'001-+ <br /> ' p OTHER p OTHER APPROX BORING DEPTHsy, 1 PN� )(BOLTED TRAFFIC BOX ort]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? IVO _(if YES, list specifications here) <br /> 'COMMENTS W 1 cl rt lied ]0 5 Q r <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 /> 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 Title/Company r�r "S ✓/✓tGe <br /> Print Name �+ Date ` Z <br /> DEPARTMENT USE ONLY <br /> ' <br /> SITE MAP N I UNIT IV FILE,ADDRESS: 17.17 <br /> WORK PLAN DATED: -?i O/ <br /> Application Accepted By SADate Issued .� Z~ Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> OMMENTS I CONDITIONS <br /> ACCOUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE �' PERMIT I SERVICE REQUEST# INVOICE <br /> ' �? DZ 3 SIR �O <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit ✓Encroachment doc 1/25/02 <br />