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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />0 N • &P <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 San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />CAP,4LAv.. Assessors <br />WELL Location (0 1/ 2-1 •09Pri‘L AV R. Cross Street TN 014n3..n AD City L p0 1 Zip 951 Y Parcel# <br />esz,Koes <br />PROPERTY Owner Lif,AN't MtrifterSO al) Address P. o. Ox of(/ City w•toPessoft zip cf 5151 Phone# to9-36 7 931Q <br />C-57 Contractor A4 vilwAtD 4 v . Address SS 7 sfrmw A P. City 5ToCr d'tn Zip" "I 5- Lic# 1U6 2 13hone#4.51 V 1P ?-1 0 II <br />Consultant/Sub Contractor A • G. F— • Address 53 7 .5,11fiv.i RP City 5rOcrT0ALic# 178 On ;honeVt 0 9 - 7 fDO If <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL/ BORING ( CPT,(EQPROBO-IYDRQPUNCH, Hi3tID-AUGER, OTHER*) l] DESTRUCTION (choose type below) <br />g SOIL BORING # i' • 3 io I r • 37 []OVER-BORE <br />U WELL # 0 PRESSURE GROUT <br />*Other: ' U.s tb.C. Gjout Specifications: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2" MULTIPLE CASINGS? a YES a NO WELL CASING DIA:/41/19. <br />CASING THICKNESS fV/A- TYKUWASING: STEEL PVC OTHER: <br />DEPTH OF GROUT SEAL 11+43 L.— i/ TFItMIE TYPE TO BE USED: Ej AUGERS ,HOSE <br />GROUT SEAL PUMPED: U Y9? (No (NOTE: MAXIMytF_REE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: rt,it flan 0 <br />APPROX. BORING DEPTH 55 F- I, a BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS: <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 Regulations, and all applicable California tate Laws. <br /> <br />cit,;51- , Signed x 1 . rialt 1-- W0--- Title/Company T 6 / /4- G. irc-- <br />Print Name IT. 0 o 714...../ ..1 . ct., , I /etc- Date toe/ '''' / 15 '• Z. <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, AldY:113pS: <br />WORK PLAN DATED: <br />617 Zeeet <br /> <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS! CONDITIONS. <br /> <br />Date Issued <br /> <br />f.P-0 Area <br />Date A-6 <br /> <br />Date Final Inspection By <br />Date <br /> <br />ACCOUNTING ONLY: AID# Ctif'it <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE .,...01 4t121:tErk INVOICE <br />356 /, CO el 17 2,1,9 Qw., '• r . 003(24ey) <br />COMMENTS: S ve (No te it My Z 00 2_ <br />TYPE OF WELL <br />11 MONITORING <br />U EXTRACTION <br />U VAPOR <br />fl AIR SPARGE <br />ROIL BORING <br />El OTHER: <br />INSTALLATION TYPE <br />U HOLLOW STEM <br />a AIR HAMMER/DRIVEN <br />El MUD ROTARY <br />RUSH POINT <br />Er HAND AUGER <br />El OTHER <br />C-57 Letter of Authorization to sign per oc 1/25/02 C-57 WC -WAIVER