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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 />9 % I %-�f WkL <br />SITE <br />MITIGATION <br />UNIT IV <br />ON/ <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 />/2c / 54-, <br />� / ,�.,, Assessor's h � <br />WELL Location ZZU7 6. i-e� I� !� . Cross Street �Ur City S� 61"'t 't Zip Parcel# / ' G✓ <br />PROPERTY Owner(Uk; IC 5fD IGS Address0bl Cu4eur';se'51 . CityFre.Asowt Zip f1 5A Phone#�b S -9500 <br />C-57 Contractor 4'fGU2((P(i1 Addressi/oD//AVe+(e Ad;. City�(¢Lt`ZipqSSt73Li L Phone# � <br />Cortsuftant/SubCntrtfyri�o►t�NJ;fp�6N(,wfAL� Address5U16o -N11&j city�Lic#NbS3D� Phone#«1L%/3/-1ITO <br />-7- —T HiUs <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />kNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type belo <br />0 SOIL BORING # 0 OVER -BORE <br />Z'kVELL # MGU- 0 PRESSURE GROUT <br />'Other. —� Grout Specifications: fi <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ., <br />DIVIONITORING ; E HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 MULTI-LEVEL? 0 WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5C,n 40 TYPE OF CASING: 0 STEEL '{(,PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ( TREMIE TYPE TO BE USED: '`AUGERS 0 HOSE <br />0 AIR SPARGE / Ozone 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes X,No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: I" °�� i' 6-0-C44O'Wt <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH / BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED?AJO ( if YES, list specifications here): <br />'CO <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPLU 11UNS. <br />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />Ccu.^.t`; O:di;t#: ce=R,.-!es d Regulations, and all applicable California State Laws. <br />fij <br />Signed x 10 � // S �/ p Title/Company <br />Print Name _TQ7'ttJrd !K'�'fT� I`' �' S3G� Date 1 e <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />g -1`i -02 -- <br />ZzgS IE� . F.� , s() '-N� CDPJ <br />WORK PLAN DATED: <br />Application Accepted By. <br />Grout Inspection By_ <br />Destruction Inspection B <br />COMMENTS I CONDITIONS: <br />er^rni lm mlr. nNI Y. AID& <br />C- n Date Issued /0-Z&-�� Are <br />to lhFinal Inspection By- -Leo -t Date_ <br />Date <br />C-57_ WC ✓ -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ / <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC-D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />PE CODES <br />3 So 1 <br />Mv�t <br />t o I© <br />Ic -2- 5 <br />2-- <br />8 29/02 <br />C-57_ WC ✓ -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ / <br />