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,. San Joaquin Countyf <br /> Environmental Health Department ' <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 <br /> NN ®RN <br /> " (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> Well Permit Application RWIPUARA,.TU <br /> FERMIRSERVICEEF— <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 Tide,Chapter 9-1115.3 and the Standards of San oaqu County Environmental Health Department, <br /> WELL Location I� Assess <br /> Cross Street City���__ZIpParceGlr �0— <br /> Owner O Address ' Cl ZIp�Phorll6 l <br /> C-57 Contracto n ' Address -•� c.!cft& Cit n�u ZipI L1 nQ01ho `91 1KF <br /> Cofwuft t/Sub Cntr Address_ 1 ]fes:r,►2 C1ty—Lplc � 2. Phone* K l� <br /> GIS Coordinates:X Y .Township Range Section <br /> EW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) n DESTRUCTION (choose We below) <br /> 11 SOIL BORING S n OVER-BORE. DIAMETER <br /> 4467-!! 11 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: W <br /> TYPE OF WELL -� <br /> *WNITORING OLLOW STEM DIA.OF BOREHOL a MULTIPLE CASINGS BMULTI-LEVEL WELL CASING DIA: a4 <br /> n EXTRACTION ©AIR HAMMER/DRIVEN CASING THICKNES�4 TYPE OF CASING: n STEEL �VC <br /> BOTHER: <br /> VAPOR n MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: StAUGERS o HOSE <br /> If AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes ArRo (NOTE: MAXIM M FREE-FALL DEPTH IS 30') <br /> o SOIL BORING n HAND AUGER GROUT SPECIFICATIONS 41� <br /> a OTHER: n OTHER APPROX.BORING DEPTH---Q—<L'— BOLTED TRAFFIC BOX or o STOVE PIPE <br /> COMMENTS• CONDUCTOR CASING PROPOSED Of YES,fist specifications In comment section) <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 OrdinancP, Rules::d�egulatlona,and all applicable Callfom State Laws. <br /> x Tfile/CompartyVVgrM& 6gDW15+ <br /> Print Name ! Date <br /> DEPARTMENT Uft ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: r �rt <br /> APp Accepted By Data Issued -+w Area 3`11 <br /> m <br /> Grout on BY Date Final Inspection By Date <br /> Destncon Inspectim By Date <br /> COMMENTS I CONDITIONS. <br /> ACCOUNTING ONLY: AID* PAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK 0 RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> •� z ..., 3 '1'4. (, 33 Q­ sR*ooA3 <br /> -DOb JIM <br /> C-571/ WC✓WArVER-t�A C-57 letter of Authorization to sign permitl�Encroachment dor <br /> EED 29-02-Ml <br /> 6/22104 <br />