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WELL PERMIT APPLK"_--ATi0N FORM <br />SITE <br />SAN JOAQUIN COUNTY MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <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 Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location_ 't)T>j[- M„ f.,�,�.� Cross Street /�� Assessor's <br />esCi 5M -,n QJ City 1 t �y Zip 53"1 b Parcel#_25 3 - <br />PROPERTY Owner i C- 74A <br />Address Q) C-hrf r ,n ? �i <br />i�d . City Zip LPhone# <br />C-57 Contractor 6recG �ridi,� � `�Tedress iso Clty Zip • Lic# '�eSlb� Phone# _ <br />4S'=i <br />Consultant /Glib Gem4mctoT__(U Address :3is7 �f. <br />---_City t 1{tLic# — Phone#Qit&7ft - 9-%cc_ <br />GIS Coordinates: X 'Y S"z V_ -.*--,u <br />Township Range Section <br />WORK TO BE PERFORMED: <br />W WE� / BORING (CPT. GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) Q DESTRUCTION choose <br />Q SOIL BORING # ( type below) <br />614VELL #_"t z-\S� — oZ a3 0 OVER -BORE <br />'Other: 9 pkkuLL aek-Grout Specifications. Sze Q PRESSURE GROUT <br />COMMENTS.�{�,, r Ong r@ <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />Q MONITORING &HOLLOW STEM DIA. OF BOREHOLE �" MULTIPLE CASINGS? BYES "0 WELL CASING DIA: I � <br />Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS '�C�' AO TYPE OF CASING: STEEL <br />�'C Q I'�O Q_OTHER: <br />Q VAPOR <br />Q MUD ROTARY DEPTH OF GROUT SEAL_:!!:.5 `� TREMIE TYPE TO BE USED:. © rJGERS Q HOSE <br />Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: es , <br />Q SOIL BORING 0'� Q No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30 ) <br />Q HAND AUGER GROUT SPECIFICATIONS:2 �� <br />4' Q- % 6f ` �z r"' x <br />�6THER: b ie _yam[]] OTHER APPROX. BORING DEPTH " � Q BOLTED TRAFFIC BOX or ReSTOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here):_ <br />'COMMENTS: 7r S�-c7 l to•+ �.vy rnr: , r� 7 % 7�r^-'� APt^' t C-- 0.'t c <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 Sari Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x ��tJ�•t.� i Title/Company- <br />i� nest R <br />Print Name Date <br />DEPARTMENT USE ONLY <br />Si TE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted B Date Issued_ Area 7 '? <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />enr`te <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PER EST # INVOICE <br />;9'OD 8100 ass 76 ?i! b R# Uv g c <br />C-57 WC_ -WAIVER C-57 Letter of Authorization to sign permit_ EncroaC men 7-Toc 1/25/02 <br />S <br />