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WELL PERMIT APPLICATION 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 />f (209) 468-3449 <br />ft 0, 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( -71 .. -.L - <br />__Cross Street tr � 1 c,,,�n p�< jCity r Zi ��� Assessor's <br />(L- c(� �' SN is A�� P �� Parcel#_ :,( 5a-�7a - L <br />PROPERTY Owner. 73r> -rr,,Ce <br />Address <br />C-57 Contractor G- e fi �'�—C'ry :D:E1 ZiP �1SL' Phone# <br />fi i� ;'(t, ,�nnra^f S Address4-3R- 140 <br />g <br />Ci <br />i(r+ n R. , i frkhtz `taS-- <br />b Zip=i+{50Lic# yT5rL SPhone# 'a'i.41-- C <br />Consultant/Sub- OniFeeterlliH35 Q'nrrn-_2.' �, Address` <br />—f2C•G,lr (' City SGr+WrnnD(LUc# Phone# �ti6'6� f-aL©C <br />GIS Coordinates: X Y <br />Township Range <br />Section <br />WORK TO BE PERFORMED: <br />U NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) <br />SOIL BORING # @''DESTRUCTION (choose type below) <br />fl WELL # <br />'Other: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />U MONITORING <br />PfiOLLOW STEM <br />U EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />U VAPOR <br />U MUD ROTARY <br />U AIR SPARGE <br />U PUSH POINT <br />0 SOIL BORING U HAND AUGER <br />[KOTHER:� e_ - a OTHER <br />`COMME <br />u'OVER-BORE <br />Grout Specifications: `>C������ u"PI�ESSURE GROUT <br />r' <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE L ",�, <br />MULTIPLE CASINGS? u YES li'i`iv- WELL CASING DIA:_�i <br />CASING THICKNESSTYPE OF CASING: U STEEL 9-rVC u OTHER: <br />DEPTH OF GROUT SEAL rREMIE TYPE TO BE USED <br />GROUT SEAL PUMPED: ;' {eS U AUC;ERS u HOSE <br />p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: "TySY•��[Tl'lr {��p( ,si <br />'V'16Z-�' c,, <br />APPROX. BORING DEPTH " 3-X 53' b t U BOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED? tt ( if YES, list specifications here): <br />r in S F ZT.YYlP � y 'I't•'1c � [ 1 -1 t- 1 ., , <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS ORENCROACHMENTPERMITS Iib <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 willbe done in accordance with San Joaquin <br />County Or Rules and Regulations, and all applicable California State Laws. <br />Signed x-, <br />c_ Title/Company_t�n,;e� <br />Print Name ay -o&% t j t,, .� <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />'7 <br />Application Accepted By . <br />9 ? <br />Grout Inspection By _I Date Date Issued Final Inspection vo Area9 <br />By <br />Destruction Inspection By Date <br />Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />rnr��t <br />PE CODES FEE INFO jAMOUNTREMITTED CHECK#REC'D BY DATE <br />sSC-57WC-WAC-57 Letter of Authorizcltion tr, cin, <br />PERMIT / <br />ril <br />INVOICE <br />