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,o ' op Oan Joaquin County ` <br /> Environmental Health Department SITE <br /> 600 E. Main Street, Stockton,CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.Sjgov.org/ehd UNIT IV <br /> Well Permit Application <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 9-11 .3 and the Standards of San Joaquin <br /> � � ' C my Environmental Health Department. <br /> ssesl#e <br /> WELL Location G Cross Stree ity Zip Parceh7/-0& y7 <br /> PROPE `—`� ,// <br /> Owner 1 d AtldressXk /ldat.CityZip Ph/o�ne# d y <br /> C-57 Conlracto h to ddres City Zi�QfLij!7 h��D' D `U <br /> Consultant!Sub CntrglyAddres r ity.S(�4�Lic# Phone# •7 6 '1 •7S <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> g NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> 0SOIL BORI[G# a OVER-BORE. DIAMETER <br /> RESSl7RE"G <br /> a"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS /tl <br /> a MONITORING $'HOLLOW STEM DIA.OF BOREHOLEJZ!� a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: Y� <br /> a EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS 3 b <br /> It TYPE OF CASING: a STEEL *VC n OTHER: <br /> a VAPOR u MUD ROTARY DEPTH OF GROUT SEAL__C_TREMIE TYPE TO BE USED: PUGERS a HOSE <br /> a AIRSPARGEI OZONE p PUSH POINT(GP orCPT)GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FA L DEPTH IS 30') <br /> U SOIL BORING a HAND AUGER GROUT SPECIFICATIONS (�tx�cw✓i; C t <br /> p OTHER: 0 OTHER APPROX.BORING DEPTH_ �� p BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: i7cs4ra..n�-orn vl.c. tn, .(n+ta._ �.ty� �,.ura,.✓t S1N�� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> Count*rdanres ules an tions, and all applicable California State Laws.Signed xTitle/CompanyLW <br /> Print Na1� ate <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ( `!s L� �`[ g� I Mo(✓ Ft C"L_ <br /> 0 <br /> WORK PLAN DATED: e Q <br /> A <br /> Application Accepted By '!� `� Date Issued Zi '� Area 36 f- / <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST If INVOICE <br /> �,R.dt fk.00 gq��J 3'S�t Ll•s' l SR#�6�'Il <br /> C-574/' WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> EHD 29-02-001web r0fe'> Lq -t - <br /> 622/04 <br /> �. w ont�l4wv <br />