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` San Joaquin County 9Rt011xWWWxyW1WW <br /> Environmental Health Departmen <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 F lIM1�l�l�N <br /> lop <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/ehd EWIROM. - TAutI <br /> Well Permit Application PEF <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED Icatlon is made In compliance with San <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This appl <br /> Joaquin County Development Title,Chapter 9-1115.3 and the StandardsZ�rclty <br /> unty Environmental Health Department. <br /> Q roes Street A Zlp Parcels .. <br /> WELL Location <br /> PROPEVst t.L Phone* <br /> p Address "kc' -/ <br /> Zip <br /> Owner � � -�� n �. /[� <br /> Address CZip{ L�j=P 7l (V7 <br /> C-57 Contra d _ l <br /> Consultant 1 Sub Cntr <br /> Address %fes—_C Phone; <br /> QIS Coordinates:X <br /> Y Township Range <br /> �rEWWELL l BORING (CPT,GEOPRO9E,HYDROPUNCH,HAND-AUGER,OTHER'S DESTRUCTION R BORE. DIAMETER(choose below) <br /> Q SOIL BORINGS la PRESSURE GROUT <br /> WELL S GROUT SPECIFICATIONS <br /> a & <br /> COMMENTS: <br /> TYPE OF WELL ml �4 <br /> "ITORING OLLOW STEM DIA.OF BOREHOL %� []MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DlA: <br /> p EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNE��TYPE O�CASING: STEELYG p OTHER: <br /> n VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL-2`_�TREMIE TYPE TO BE USED: �14UGER5 Ij HOSE <br /> Q AIR SPARGE!OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes Flo (NOTE: MAXI!YM FREE-F LL DEPTH IS 30') <br /> Q SOIL BORING U HAND AUGER GROUT SPECIFICATIONS BOLTED TRAFFIC BOX or STOVE PIPE <br /> OTHER, ---A _,OTHERAPPROX.BORING DEPTH <br /> -CONDUCTOR CASING PROPOSED (if YES,list spectficatlons 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 Ordinan 9g,Rules and egulations,and all applicable Caltforn State Laws. <br /> Signed <br /> Title/Company r S <br /> x <br /> Print Name Date s <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV RLE,ADDRESS: <br /> WORK PLAN DATED: ^'i <br /> Application Accepted B ' ' Date Issued '� Area <br /> Grout Inspection By <br /> Date to is Final Inspection BY Data o l-t.- o L' - <br /> Destruction Inspection BY Date - <br /> COMMENTS f CONDITIONS: <br /> ACCOUNTING ONLY: AIDS FACS <br /> PE CODES FEE INFO AMOUNT REMrrTED CHECK S RECD BY DATE PERMIT I SERVICE REQUESTS INVOICE <br /> 3 Zrs..� 3 '��� a4�3 3 SR*ooA 20 <br /> .oi, <br /> C-571,—` WC_!L--WAIVER:tA�N C-57 Letter of Authorization to sign permitr ..Encroachment doc <br /> ia <br /> EEID 24-02-001 <br /> 6122104 <br />