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17 <br /> ild <br /> San Joaquin County <br /> Environmental Health Department <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 952 MMN <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/e <br /> Well Permit Application P <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , <br /> Application is hereby made to San Joaquin for ENVII�t���1�VIENT HEALTH <br /> ►y P t4 construct of Sant aquinE the work Environmental <br /> This 1ppli�V�� �n�with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San JQoaqujin County Environmental Health <br /> WELLLocatlon _ r j ,W•6t1�t�✓105�a� Toss Street Yt� ¢ City Zipq 7 Ass Bao 118 O <br /> PRO <br /> Owner Ie vvl. Address—W-71, Clh'S p-r_ Pi Phone* l - -4>--7 <br /> C-457Contractor ri, dress +PG '� CilyAa d&P _ZIP 2/IU(O��ho <br /> Comaltant/Sub Cntr Addresa_Q���City L cs 687 Pho <br /> ne; V C/ -7 <br /> 019 Coordinates:X Y ,Township Range Seton <br /> -OEW WELL/SORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTRUCTION (choose type berow) <br /> Q SOIL_BORING S Q OVER-BORE. DIAMETER <br /> -jeWELL S MW! d-- Mr <br /> ��� ©PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> I=OF YYELL <br /> `VIIONITORING OLLOW STEM DIA.OF BOREHOLE 5+;•• Q MULTIPLE CASINGS [IMULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION 11 AIR HAMMERIDRIVEN CASING THICKNESS_TYPE OF CASING: Q STEEL Q OTHER: <br /> VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL_�i f fi#- TREMIE TYPE TO BE USED: gtAUGERS Q HOSE <br /> Q ALR SPARGE!OZON E Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes 50o (NOTE: MAXI UM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS 9 <br /> a OTHER: rl OTHER APPROX.BORING DEPTH, ;Ls�i A�SOLTED TRAFFIC Efox or Q STOVE PIPE <br /> COMMENTS: 'S <br /> CONDUCTOR CASING PROPOSED„ (H YES,list speclllcattons In comment section) <br /> , <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 Ordinancea,Roles and Regulations,and all applicable Callfornia State Laws. <br /> Strod X e TltlelCompany Q y�N,A0 <br /> Print Name f i� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED' <br /> Application AcceptedBy Date les36 1 <br /> Grout Inappotim By Date Final Inspection By <br /> Damon Inspection By Date - <br /> COMMENTS 1 CONDITIONS ••- <br /> ACCOUNTING ONLY: AIDS FAC* <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK 111 RECD BY DATE PERMIT/SERVICE REQUESTS INVOICE <br /> .,� ( C3t� zq�ktdl 1 Cu-�y rsCp- SRO 0V11jj1 <br /> C-57 Z WC -WAIVE .+N C-57 Letter of Authorization to sign permit Encroachment dock <br /> Elm 29-02-001 <br /> 6r22104 <br />