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WELL PERMIT APPLICATION F ARM <br />MECE JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />JAN 3 2002 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />ENVIRONMENT HEALTH (209) 468-3449 <br />PER <br />SITE <br />MITIGATION <br />UNIT IV <br /> <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 Zan <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />C-7 1,Jet,.'nOrC Cross Street fri.:ifi1 City Zip q$ ) parcei# t -ci,t -0 <br />PROPERTY Owner ../1:11-6 kr\-f- Ck Address I DO I Ce ..friz.ii-feceL op'!53) Phone# )3°5 <br />C-57 Contractor ft! ci it( Address eb ,eQjj city Phone'))IW7 3/1:;C7 <br />Consultant / Sub Contractor Address .`1)3) 51-1/;14; City 5+ale t/Lic# 6‘2,..Q) Phcne# La; -ye& ),s <br />GIS Coordinates: X , Y <br /> <br />, Township Range <br /> <br />Section <br /> <br />WELL Location <br />WfilORK TO BE PERFORMED: <br />r..INEW WELL / BORING ( CPT, GEOPROBE, llYDROPUNCH, HAND-AUGER, OTHER') <br />OIL BORING # 2-7 in 5 <br />a WELL # <br />*Other <br />COMMENTS: <br />a DESTRUCTION (choose type below) <br /> CI) <br />0 OVER-BORE <br />0 PRESSURE GROUT <br />Grout Specifications: <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />U MONITORING a HOLLOW STEM <br /> <br />0 EXTRACTION a AIR HAMMER/DRIVEN <br />VAPOR 0 MUD ROTARY <br /> <br />U AIR SPARGE )11:5USH POINT <br /> <br />'SOIL BORING 0 HAND AUGER <br />OTHER: flOTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS fi <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES a NO WELL CASING OW / <br />CASING THICKNESS /4/Vi TYPE OF CASING: 0 STEEL fl PVC 0 OTHER: <br />DEPTH OF GROUT SEAL e-ict, TREMIE TYPE TO BE USED: a AUGERS 4-HCSE <br />GROUT SEAL PUMPED: 11,Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 20') <br />GROUT SPECIFICATIONS: (-Ce A-kJ Ce-le4 <br />APPROX BORING DEPTH Ic 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PRCPCSED?71,/4" ( if YES, list spedfications 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 />this application and that the work will be done in accordance with San Joaquin <br />lations, and all applicable California State Laws. <br />Title/Company &JO/ 02 /54- <br />Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: A. 10 (A) -CA-1/1".0 <br />WORK PLAN DATED: <br /> <br />I hereby certify that I have prepared <br />County Ordinances, Rules and Regz_ <br />Print Name <br />Signed x <br />! <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date Issued I ( Area <br />Date I I 5S.i 6 Z. Final Inspection By k../f:;)-eAA,V*c..i.n, Date <br />Date <br />COMMLNT5 I 1.;uriuli mina: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE QUEST # INVOICE <br />3 Co 1 CC CA .cc) I & 0 Cj q ci-,( 1 0 sR#00x5< 5 )-3-- <br />— ____, _I _ _ 0/971(10 <br />C-57 <br /> WC -WAIVER <br /> C-57 Letter of Authorization to sign perm ncroa