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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <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 />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />e,\J CM <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 />C.rty,_rt2tt /.& Assessor's <br />WELL Location 2 WCi £.,rya'pt,A��e-v�,� L Cross Sltr/ee�t/ � I�lt+Ct<C. City l�- Zip Parcel# <br />PROPERTY Owner �kl It ST�l1 gar 15 Apddress� yl�l7p f�:Kl�Yn(�Se Cj{ City Zipq Phone#� L `�i }-gSOa <br />C-57 Contractor ;(( Address 502 r.GC City %Vw Zip!fq55!lLic#-14$516SPhone#LIIS)-313-58e)o <br />Consultant! Sub Cntr Vtt K I►+1–AddressriOJ((sJ(dEu PrkwyCitytr i,%& Lic#K a'+ Phone#a4q* <br />6 ' <br />GIS Coordinates: X Y Township (,� Range Section Seg <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDRO <br />�CSOIL BORING #–'I' <br />0 WELL # v,- n > > <br />`Other: <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING 0 HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE / Ozone 0 PUSH POINT <br />SOIL BORING 0 HAND AUGER <br />0 OTHER: OTHER C �� <br />D -AUGER OTHER` y{-Vq 0 DESTRUCTION (choose type below) <br />n s 61 � +� D OVER -BORE <br />2. 0 PRESSURE GROUT O� <br />Grout Specifications: X,#, f±!� Sti�tc. <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE I-" MULTIPLE CASINGS? 0 MULTI-LEVEL? 0 WELL CASING DIA:%"'O"4`Q� t <br />CASING THICKNESS l TYPE OF CASING: 0 STEEL 0 PV<�: �— <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH SD " 100 ' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CnNnt ICTOR CASINO; PR(lP(l.4Fl» N D t if YFS li-t cnarifirntinnc harp\ <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 Ordinaq�es�Rules a! nd Regulations, and all applicable California State Lawn . 1 _ <br />Signed <br />Print N2 <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: g�1� 2 -- <br />Application <br />Application Accepted By <br />Grout Inspection By_ <br />Destruction Inspection B <br />COMMENTS / CONDITIONS: <br />Date Issued 72— ! 't 2' Area 0 <br />Date Final Inspection By <br />Date <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />3�0! , 51'5,r <br />���o <br />f%032ro8 <br />C-57 ✓ WC V' -WAIVER_ C-57 Letter of Authorization to sign permits Encroachment doc 8/29/02 <br />