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SAN JOAQUIN COUNTY SITE <br />D_ tRONMENTAL HEALTH DEPARTi,--NT MITIGATION <br />304 East Weber Avenue, 3 Floor, Stockton, CA 95202-2708 UNIT IV <br />(209) 468-3449 - Fax: (209) 468-3433- Web: www.co.san-joaquin.ca.us/ehd <br />\FpR <br />WELL PERMIT APPLICATION FORM <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED U <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is nxpdg ' compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Departmer "I'"' <br />ENVIR Assessors <br />WELL Location .208'-5 �iCCf-M oN> S 77 Cross Street L �y� City S i o�K To^� ZEA �r' �t���� l-��f arpejq� /4// //?- 0-T <br />PROPERTYOwner sc- ei 7:ev0P1,+✓0 Address Z3Z(- /'r/FAs,}M RwW CCity S'TocK>ZipiSs07 Phohe#' 43 3 Q373 <br />C-57 Contractor W dog w � Address P. O . Z oX 3 3 City e a Vis-rA Zip 9f�S'7/ Lic# 7/0 o79 Phone# 707 X791f:. <br />Consultant / Sub Cntr A iG it-Ssbc, A %CS' Address //17 4o.JC PA[, &'I AUC City/!0'bC-t'7Q Lic# Phone# !r79 ZZZ/ <br />GIS Coordinates: X <br />Y <br />Township <br />Range Section <br />WORK TO BE PERFORMED: <br />REC'D BY <br />DATE_/ <br />0 NEW WELL / BORING (CPT, <br />GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />ff-DEST WCTION (choose type below) r <br />0 SOIL BORING # <br />OVER -BORE -DIAMETER / Z <br />0 WELL # M <br />SRO <br />0 PRESSURE GROUT <br />0*Other: <br />Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />ONITORING <br />0 HOLLOW STEM <br />DIA. OF BOREHOLE <br />MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: 0 Yes <br />0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS: <br />0 OTHER:_0 <br />OTHER <br />APPROX. BORING DEPTH <br />0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS: NCAT <br />C)Lt <br />a,i <br />i-e i <br />NOTE: <br />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 Ordinances, Rules aryl Ro6ulations, and all applicable California State Laws. <br />Signed x e—�y <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: A <br />WORK PLAN DATED: 3/34SI( , S <br />Title/Company fi <br />Date _g <br />S <br />DEPARTMENT USE ONLY <br />Application Accepted By 0 Date Issued_ Ll <7 /C; 5 Area 2- V � <br />Grout Inspection By�il��� . �. r o1 _ Date L O - Final Inspection By [A Ace... Date <br />Destruction Inspection By Date <br />COMMFNTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# '5) j(J <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE_/ <br />PERMIT/ SERVICE REQUEST # <br />INVOICE <br />SRO <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br />EHD 29-02-001 WELL PERMIT SITE <br />8/27/2003 <br />