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WELL PERMIT APPLICATION FARM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> IV <br /> FED - 2006 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRON-O,ENT IIEALTk (209) 468-3449 <br /> PFQe•`,�ITicG?�riCES <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 <br /> WELL Location v2 Q / �u`r /,y Cross Street TIl/C Ley//S City Zip O Parcel# <br /> PROPERTY Owner�a�e CQ'/ G G Address 20 City fi G� ZipS �205hone#-ff! �� <br /> C-57 Contracior-40�" Address � Ci �e' Zi Zg�, Lic# Phone# <br /> Consultant/Sub Contract or�tPO!'11Cr fP ���/� Address927 /v?�� Phone# <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> OIEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> �0p SOIL BORING# Q OVER-BORE <br /> p0 WELL# Q Grout Specifications: PRESSURE GROUT <br /> 'Other: �jlrSS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> OONITORING OOLLOW STEM DIA.OF BOREHOLE�r- MULTIPLE CASINGS?Q YES '00 WELL CASING DIA,- <br /> EXTRACTION <br /> IA- <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSf jj `1O TYPE OF CASING: Q STEEL PVC BOTHER: <br /> Q VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL,!5P- 5- TREMIE TYPE TO BE USED: ('AUGERS 0 HOSE <br /> Q AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Q Yes o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: C SSS <br /> Q <br /> OTHER:_0 OTHER APPROX.BORING DEPTH nZ6�17 ,BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CO UCTOR/CASING PROPOSED? �(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 /> 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 Regula ions, and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Name ST�d Gam'' Or Dater 3 / — <br /> DEPARTMENT <br /> USE ONLY, <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 205 l - <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> Date Issued 11(o l7 Area 9� <br /> Grout Inspection By d -� Date c O Final Inspection By Date <br /> Destruction Inspection By nDate <br /> COMMENTS ICON DMON S: <br /> ACCOUNTING ONLY: AID# Gert <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> k 3S61 F1 8e - l20gK- IZJ/y os sR# Y/2/ <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ 1/25!02 <br /> 3ST63 J-? C-?q J X70 N� Z���o- <br />