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EASAN JOAQUIN COUNTY SITE <br /> ONMENTAL HEALTH DEPARTMO, MITIGATION <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 UNIT IV <br /> o P (209)468-3449 •Fax:(209)468-3433• Web:www.co.san joaquin.ca.us/ehda Y <br /> WELL PERMIT APPLICATION FORMIRE L <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a pemut to construct and/or install the work described. This applicatioM"(Q ii jxiiJ66ce with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> WELLLocation�//�M'' 't-I:�yei�o.rdcWV-TTrossso-eet city zp ENVIROP�f �Z <br /> PROPERTYOwneryety CR—I'p�WaA30wk Address 6-It"ll3'p`� CityWC �kzp4 �Ph«,e# 69—'ltd,$ <br /> C-57 Contractor l l�oac�Worr�. Address�.��,\�/�`S"1�pov�G _1� .Zi -1 I Lic#�It:b�Phone#6- 31'4-AZC= <br /> n th� <br /> Consultant/Sub Cntr Kv1 Address '"35.YC5eyv\ City t4jc# Phone# '305 <br /> GIS Coordinates:X ,Y-,TownshiPRange Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# / 0 OVER-BORE-DIAMETER <br /> WELL#_ �- y_i/�'!i �I/i.k/ OPRESSURE GROUT <br /> 0 Other ^Y't� �lf.�!/ Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> r/ <br /> MONITORING `HOLLOW STEM DIA OF BOREHOLEja _MULTIPLE CASINGS?0 YES*0 WELL CASING DIA:+ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL )K-VC BOTHER: <br /> 0 VAPOR " 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: <br /> 0 AIR SPARGE l7 AUGERS HOSE <br /> p PUSH POINT GROAT SEAL PUMPED:�l'es p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUP SPECIFICATIONS,20 vay r,CE�-�b post-�• .c�cavVT�t`..CSE <br /> 0 OTHER: N OTHER APPROX.BORING DEPTH 0 BOLTED T FIC BOX or XSTOVE PIPES �� <br /> CONDUCTOR 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 /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, R les aq4jRegulations, and all applicable California State Laws. <br /> Signed x T'ide/Company6r. <br /> Print Name <br /> - ?."tY�on�� 1". Date �� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,AD RESS: 93-70:V5. fw c V V Q <br /> WORK PLAN DATED: / I _ <br /> Application Accepted By �Y �Qi Date Issued Area U. o <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: _--- <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO I AMOUNT REMITTED CHECK# RE 'D BY AT PERMIT I SERVICE REQUEST# INVOICE <br /> no SRtt Z-& <br /> C-57_ WC=WAIVER_ C-57 Letter of A horizati to sign permit-Y- Encroachment doc <br /> FHD 29-02-001 WELL PERMIT SITE <br /> 8/272003 <br />