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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Jcaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Developmegqt T+I C' ter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> /YD LV ' � Assessor's <br /> WELL Location-40 �cJE 0Q� �l7Cr ups Cross Street City S�aLlLti�ri,.- Zip Parcel# <br /> �wwQ i2 <br /> PROPERTY Owner Address -34S KI• F I Ibr n roc ' 'Ci1ty Sob S li tG- Zip Phone# <br /> C-57 Contractor Scr Address_ I(C(^l�]or ilmn 1A� .4 Zip Lic#5tLZ6 Phone#4b5-$1l0 r <br /> �Eul�tan)lSub Contractor �� lt�Y SAddress 1114 �Aw� ,S''CitY3 ex CityF-s,4, Lic#Phone# <br /> GIS Coordinates:X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type e!ow) <br /> SOIL BORING# 0 OVER-BORE <br /> tgwE L#Win,,.) 2 0 0 PRESSURE GROUT <br /> 'Other: GrcutSpecificaGons:�)PCi�I C � <br /> COMMENTS: p -flow <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE �tRi MULTIPLE CASINGS?0 YES �NO WELL CASING C1,4: Z�Kt-�_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5r'-1A9b TYPE OF CASING: O STEEL �f PVC O OTHER: c <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ??��clGv +t.TREMIE TYPE TO BE USED: `AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUN/IPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') , <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONSNAPxk C. ,1. 4 'sl➢-++� <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPT4L±H SD � OLTED TRAFFIC BOX or 0 STG'JE PIPE <br /> CONDUCTOR CASING PROPOSED?_I`7 (if YES,list specifications here): <br /> 'COMMENTS: <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 Or inan Rules and Regulations, and all applicable California State Laws. <br /> TZ <br /> Signed x Title.'Company_, �� CtS � r <br /> Print Name !J Date lUI3v�0 3 �, <br /> DEPARTMENT USE ONLY <br /> c� <br /> SITE MAP IN UNIT IV FILE, ADDRESS: rr <br /> WORK PLAN DATED: � <br /> nn pp �1- <br /> Application Accepted B <br /> ,�,-et Date Issued ills/2 Area <br /> Grout Inspection By <br /> Date ( l� Final Inspection By Date___ <br /> Cestructicn Inscection By Date <br /> C0?.1PdENTS!CONDITIONS: k <br /> ACCOUNTING OY: AID#PE CODES I NFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �i" Dl- / '1 I�!�.��3 D <br /> -=,7 V!,— -vVATVFR C-57 Letter of Authorization to sign permit_____ Encroachment doc 1/25/02 <br />