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WELL PERMIT APPLICATION FZ3ttM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <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 Tittle, Chapter 9-1115.3 Fd the Standards of San Joaquin County Environmental Health Department. Assessor's <br />WELL Location /rG OS�Cs .'i/f �i d��ross Street City / ip Parcel# <br />/ Address j ��City �� ZIPZF'hone# <br />PROPERTY Owner — ' �C�� -,�� <br />C-57 Contractor <br />ddress! ��i/ CityZiPic#/,6501�hone#_g/ <br />Consultant /Sub Contractor_ �/j YZ ' Address ��f>.� �� City,(�ic# Phone# 9T Y/-%' <br />GIS Coordinates: <br />u <br />Township. <br />Range Section <br />WORK TO BE PERFORMED: <br />CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) <br />DESTRUCTION (choose type below) <br />NEW WELL / BORING ( <br />Z D Areae_ <br />0 OVER -BORE <br />Date <br />0 SOIL BORING # <br />�. Date <br />0 PRESSURE GROUT <br />Qj <br />� n��t <br />0 WELL # <br />Grout Specifications: <br />p <br />'Other: <br />Date <br />C <br />Gn <br />COMMENTS: <br />COMMENTS/ CONDITIONS: <br />O l <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS�fM/ r <br />DIA. OF BOREHOLE i' " MULTIPLE CASINGS? BYES ONO WELL CASING DIA: _ <br />ONITORING <br />FOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS �!L TYPE OF CASING: 0 STEEL VVC 0 OTHER: <br />0 EXTRACTION <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL"TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 VAPOR <br />CHECK # <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: <br />MAXIMUAfI FREE -FALL DEPTH IS 30') <br />INVOICE <br />0 AIR SPARGE <br />0 PUSH POINT <br />'I� 7L <br />ZS / -e: <br />sR# <br />J�SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH <br />J'BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER:_G <br />OTHER <br />CONDUCTOR CASING PROPOSED? <br />(if YES, list specifications here): <br />O <br />C-57 WC -WAIVER <br />'COMMENTS: <br />AInTF- OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REGZUIKtu INZWr-%, i ivj.0. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />Countyd' _ ncq�/ and Regulations, and all applicable California State Laws. <br />Signed <br />Print Name <br />SITE MAP IN UNIT IV <br />WORK PLAN DATED <br />DEPARTMENT USE ONLY <br />Date Issued <br />Z D Areae_ <br />Application Accepted By <br />Date <br />Final Inspection B <br />�. Date <br />Grout Inspection B�y � <br />� n��t <br />Destruction Inspection By <br />Date <br />C <br />COMMENTS/ CONDITIONS: <br />O l <br />ACCOUNTING ONLY: <br />AID# <br />cer to <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY DATE <br />PERMIT/ SERVICE REQUEST # <br />INVOICE <br />PE CODES FEE INFO <br />sR# <br />b,.00 <br />C-57 Letter of Authorization to sign permit <br />Encroachment doc <br />1/25/02 <br />C-57 WC -WAIVER <br />