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0C_r 2 <br />Mki, <br />M41 <br />2.285 E. �ve�.ewf 51'• <br />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 />SITE <br />MITIGATION <br />UNIT IV <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 />/� <br />Assessor's <br />WELL Location 21*Qrr G—•lrf''QV-tft/{j� 17 Cross Street 5rtYjWr City fa l Zip Parcel# i41–Z'T.iJ o <br />PROPERTY Owner VI U'jiffall Address 27A5 E• ►t�8t�f s� City T>ha Zip Phone# blVe <br />- O <br />✓G <br />C-57 Contractor . IILLC-- r ,-c Acldre/ss:i0o Ejr � �Q- City Zipq!j%3 Lic# _Phone# o <br />Consultant / Sub CntrCiUfl�`J�fI 4�fCrt7 NMt�J�t Address BK •( Gfd ity� Re Lic# 30Phone# <br />9 <br />GIS Coordinates: X , Y Township Range Section <br />WORK TO BE PERFORMED: <br />'a:NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />0 SOIL BORING # <br />SWELL # A_4.t _AJ — to <br />'Other. Grout Specifications: <br />CnMMFNTS <br />TYPE OF WELL <br />INSTALLATION TYPE <br />` `MONITORING <br />'5_}IOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE / Ozone 0 PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />0 OTHER: 0 OTHER <br />'COMMENTS: <br />0 DESTRUCTION (choose type below <br />0 OVER -BORE <br />0 PRESSURE GROUT LT\ <br />CONSTRUCTION SPECIFICATIONSr( O <br />j <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 MULTI-LEVEL? 0 WELL CASING DIA: L <br />CASING THICKNESS_ TYPE OF CASING: 0 STEEL bPVC 0 OTHER: �- <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: `-AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes Xwo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: IIID (' e <br />APPROX. BORING DEPTH lo 6 f 6OLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? la ( if YES, list specifications here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL RL:QUIKtu INSrtG I IUNJ. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />Countv Ordinan77, <br />les and Regulations, a d all applicable Californi State Law% <br />Signed x Title/Company '� <br />Print Name x1Wd 53V-7- Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: -+� �� r t-oP <br />WORK PLAN DATED: g -1 "f -02 <br />Application Accepted By_ <br />Grout Inspection By <br />Destruction Inspection By <br />rnuucuTC / CONDITIONS: <br />Date <br />_Date Issued l0 <br />Final Inspection By� <br />Areae <br />Date 1� <br />ACCOUNTING ONLY: AID# Arjt <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />SCJ-� <br />1 l o 1 G <br />l'D.LS <br />�D a/0� <br />C-57 WCC -WAIVER C-57 Letter of Authorization to sign permit ✓ Enc chmenT aocV• <br />