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Ifttan Joaquin County c) <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 952027MITIGATION <br /> • (209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/eAAP UNIT IV <br /> Well Permit Application ENVIROWENT HE <br /> PERMIT/SERVICES <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 Joa uin County Environmental Health Department <br /> ssors <br /> Cross Street City T( Zip�[� ParceW�� 0--110• 7 <br /> WELL Location D� <br /> PROPERTY 1 C� qx—ZioqwPhone# <br /> Owner Address �1�G – �( � h�f( 2� <br /> C. Contractor G� D�� Address UuC City Zip! W L� ` 1honet� " 7r o <br /> 57 <br /> ConsuHart/SubCrmtr ni,.�. nA rn�anv9ronmentalAddress��7 c1,�_, o.i _City Stockton UCS-ERn227 _Phone* {2491467-1= <br /> GIS Coordinates:X ,Y ,Township Range Section— <br /> MRK TO BE <br /> PERFORMED: <br /> SLEW WELL!BORING (CPTEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') Q DESTRUCTION (choose type below) <br /> JMIL BORINGS 169171-1 Q OVER-BORE. DIAMETER <br /> — <br /> 0 LLSI V 0 PRESSURE GROUT <br /> 0•OtIW GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF IN§IALLMON TYPE CONSTRUCTION <br /> TFL N <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE `� 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC ll OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL t; r TREMIE TYPE TO BE USED: p AUGERS p HOSE <br /> 0 AIR SPARGE/OZONE OPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: IMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS iOC� CsX►'��r�t <br /> 0 OTHER: tt OTHER APPROX.BORING DEPTH d 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED(if YES,list specifications in comment section) <br /> COMMENTS: <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 /> County Ordinances, Rules and Reg latlons,and all applicable California State Laws. <br /> r� <br /> Signed x Title/Company �;'�W[�I <br /> Print Name ei �//1 Date ! !`of <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: W 'to`- <br /> WORK PLAN DATED: <br /> Application Accepted By. Date Issued is vet Area i <br /> Grout Inspection By Date Final Inspection By, Date 1I <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS- <br /> ACCOUNTINFONLY: AIDS FACS <br /> PE CODESFO AMOUNT REMITTED CHECKS Sr RECD BY DATE PERMIT I SERVICE REQUEST S INVOICE <br /> .?o� of qi,�,7 T I►A.Vo �` SR# '� j <br /> C-57_ WC -WAIVER.,, C-57 letter of Authorization to sign permit, Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/2104 <br />