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FILE COPY <br /> p / � WELL PERMIT APPLICATION FORM SITE <br /> / W� SAN JOAQUIN COUNTY MITIGATION <br /> I l ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> l ` 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 ��_ � �s <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby me a to SnJoaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County <br /> Development Till " ' " - 4' of San Joaquin County Environmental Health Department. <br /> R MrNri LAraE 5. 1 951 Assessots <br /> WELL Location 6 - fa R s4 H '" sg_ n F�Cross Street f VA: :F;c. Are City �I��.� ZIP ° 7 Parcel# <br /> /'q rry J rL Do /'IJO � Sf . b C, <br /> PROPERTY Owner C11� of S,cCKAddress ✓ J52t,V : CitySr,� KrorZip`Isye - Phone# Z- a5 (�13 y1 <br /> C-57 Contractor _ Addres4gyt � 'Aj57WcmW4/7hone#_�l d7Z AW <br /> Consultant / Sub Contractor 71 . G • F� , AddressOS7 .SNAw RP- City SraKrrun# 6&nZ27Phone# 2 % 5 Vb / 60Io <br /> GIS Coordinates: X., Y , Township af'/ Range 6' E Section S <br /> WORK TO BE PERFORMED: <br /> � NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') D DESTRUCTION (choose type below) <br /> 0 SOIL BORING # 0 OVER-BORE <br /> %ICNELL # 1'k/) W ) -ri 0 PRESSURE GROUT <br /> 'Other: Gr( S ecif1c/�aplions: PorTi.q r., 0 ry_PE <br /> COMMENTS: 51=E AGPP��en WoAI< k .) 14CL V; FZArVCr4 zo ,12 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> A. ONITORING )IQ <br /> STEM DIA. OF BOREHOLE S PUv MULTIPLE CASINGS? p YES 'KNO WELL CASING DIA: L_ <br /> J'� 9� <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS V o TYPE OF CASING: 0 STEEL p PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL lo F7 9 Af TREMIE TYPE TO BE - SE RUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes ANo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS. PPr EIDA) T)e P11 <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH 4$ F r B S G )(BOLTED TRAFFIC 80X of 0 STOVEPIPE <br /> oONDPCTOR CASING PROPOSED?_N2_ ( 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 County Ordinances, <br /> Rules and Regulations, and all applicable California State Laws, r <br /> Signed r� Company � <br /> Print Namr ' <br /> Date O5/ ZY/ o l <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS:. ODS / <br /> WORK PLAN DATEBy D : — $'- 0 Z <br /> Application Accepted <br /> Date Issued / " D� <br /> Grout Inspection By Date � Z Final Inspection By <br /> Destruction Inspection By Dale <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST it INVOICE <br /> 35o I rW t"' R# X6 <br /> C-57 WC_WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ 1/25/02 <br /> ^/C_ <br />