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WELLPERMIT APPLICATION F01M <br />1 } ; SAN JOAQUIN COUNTY <br />iLRONMENTAL <br />HEALTH DEPARTMENT (EHD) <br />3011. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ORM,INIAI <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 />Assessor's <br />WELL Location 2- 1 Sowtl. Nei Det We Cross Street 4sf /L, City Sfoek-tow Zip Parcel# /(� '� — �ZD'03 <br />63�oS- <br />PROPERTY Owner C,okp Address 2400 ^.,xkad CitySt•264,15 Zip 366$ Phone# 314) Z54-- 7o 73 <br />C-57 Contractor Spee-te Address Z345 tj w n City 5iockton Zip 952.05 Lic# Phone# 609 5 - 71 Z_ <br />w�Scnd <br />Consultant! Sub St b.AA<p <br />Contractor ! %���9� �er,i,ces Address �oL.»,b'. X11. -Lots City(oZL3L Lic# Phone# (L(�)Z�l' /S4-7 <br />GIS Coordinates: X .31 $5 %� Y IZI /$ lJ Township 7- Range 96 IF Section 2- <br />C3_ <br />WORK TO BE PERFORMED: <br />'NEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />0 SOIL BORING # <br />,WELL # S P <br />*Other: Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL <br />0 MONITORING <br />0 EXTRACTION <br />INSTALLATION TYPE <br />HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />,XAIR SPARGE o PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />o OTHER:_0 OTHER <br />*COMMENTS: <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE V' <br />0 PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE I• ZS MULTIPLE CASINGS? 0 YES XNO WELL CASING DIA: '3� G <br />CASING THICKNESS TYPE OF CASING: 0 STEEL VPVC 0 OTHER: 1 <br />DEPTH OF GROUT SEAL S$ TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br />GROUT SEAL PUMPED: XYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30) <br />GROUT SPECIFICATIONS: C ,•tie .a H �rc �f <br />APPROX. BORING DEPTH G S )OOLTED TRAFFIC BOX oro STOVE PIPE <br />CONDUCTOR CASING PROPOSED?— o (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 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 and Re ulations, and all applicable California State Laws. <br />C <br />Signed x �,I Title/Company 'PA I, )ry t L e /S <br />Print Na/�y / k me !c/M /�. /i . NI Date Z A(/ 2 O O Z <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 2-//-.?, <br />Application Accepted By Date Issued /L Area <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT RITTED <br />CHECK #4 <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />C-57 WC= WAIVER_ C-57 Letter of Authorization to sign permit� 1/25/02 <br />