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WELL PERMIT APPLICATION FOR SITE <br /> � c��v � � -SAN JOAQUIN COUNTY,, <br /> I <br /> ,, UNlT IV I <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) i <br /> FEE 304 E. Weber, Third Floor, Stockton; <br /> (209) 468-3449CA., 95202 <br /> �P�VIs�ONP?tcRy f KAL�H <br /> SE�`J1G�S <br /> NON-REFUNDABLE PERMIT EXPIRES I 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 /> tA, <br /> Assessor's <br /> WELL <br /> WELL LocationZZ.S% SpLCKA A IJu Cross Streeteett i _ city IDYL Zipq�57t* Parcel# 10-OZO-5-5; <br /> ul_TtLA"I �f�'f zAwia <br /> PROPERTY Owe Address Aftk)t+t CbLV�5+'-e City Zip/'f7 La 3Phone Z� `141-'x ? <br /> T TT <br /> yyyy►� t s,tr� I <br /> C-57 ContractbYtkE 411�rjki E4tV11f>MY►te }�ss �9oa e Cityt � Zipq�6b 3lic#G+ 2fc! Phone �e 4l-%t <br /> -�� --ee ��``.i , <br /> Consultant/Sub CntflOR4a#3&NJt ROOX4a l-ALAddress�fl-70�t11�40uD +t�> C kity� NkO Phone# Ido D r! _ i <br /> GIS Coordinates:X ,Y Township " Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL 1 BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER;OTHER*) H DESTRUCTION (choose type below) ' <br /> H SOIL BORING# U OVER-BORE <br /> ELL# H PRESSURE GROUT <br /> *Other: 2 b I Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> XMONITORING VHOLLOW STEM DIA.OF BOAEHOLE�u MULTIPLE CASING O ULTI-LEVEL? WELL CASING DIA:Zp <br /> H EXTRACTION H AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: d STEEL )eVC H OTHER: <br /> *VAPOR H MUD ROTARY DEPTH OF GROUT SEAL;Lut. Ll .TREM[E TYPE TO"BE USED: 'AUGERS H-HOSE <br /> AIR SPARGE 1 Ozone 0 PUSH POINT GROUT SEAL PUMPED: H Yes 0!!(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING H HAND AUGER GROUT SPECIFICATIONS: <br /> H OTHER;_H OTHER APPROX.BORING DEPT BOLTED TRAFFIC BOX or H STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? 00 (if YES,list specifications here): <br /> *COMMENTS: <br /> i <br />_ NOTE: OFFSITE BORINGS REQUIRE ACCESS OWENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby certify hat I have prepared this application and that the work will be done iwaccordance with San Joaquin <br /> County Ordin ces, Rules and Regulations, and all applicable California State Laws. <br /> Signed x r TitlelCompany ��� il�+tl.- <br /> Print Name i' Date 12 n <br /> DEPARTMENT USE ONLY ` <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Date]ssue �� % Area <br /> Application Accepted By [ L1 <br /> Grout Inspection By :'Date. Final Inspection By LIV <br /> Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> [ACCOUNTING ONLY: AID* ;,E CODES FEEINFO AMOUNT REMITTED CHECK# REC'D BY DA#PEIMIT I SERVICE REQUEST# INVOIGE <br /> 0z • b <br /> SER -3 <br /> C-57__ WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02 <br />