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E COPY ii <br /> �qo San Joaquin County COD� � <br /> Environmental Health Department <br /> J <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 AN <br /> I <br /> MIJI ION <br /> (209)468-3449 Fax: (209)468-3433 Web: wviw.sjgov.org/ehd ��v�RO <br /> N,,,.UNI IV <br /> Well Permit Application P <br /> I <br /> iTk-1 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �I?14S, Iry <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install.th work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin Co Anty Environmental Health Department. ' <br /> ° fAssessors <br /> WELL Location ��2a Al- C��'= S7 Cross Street ` //f1� ity Azwo '� zip !J Parcel# <br /> I� <br /> PROPEM SHIVI O�NS7 O <br /> Owner 7� Address 4 A G- City. 7 ,e 70^1 Zip `?S�/2 Phone# <br /> C-57 ContractorWvGCT/f4JA1 6y Address &.5 4114 k/44-M d12- City� ✓��� Zip 9��ic# 1__/274hone# <br /> Consultant!Sub CntrfiWHa a/w-i,'1V60*&�-Address 'yffg 7 Phone# 9/l0 7�Q5-1d7 <br /> GIs Coordinates:X Y Township Range Section <br /> RK TO BE PERFORMED: <br /> NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OT ER') Q DESTRUCTION (choose type below) <br /> OIL BORING# a OVER-BORE. DIAMETER <br /> /1WELL# 04 W - 11 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: I <br /> PE OF WELL IN TALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF.BOREHOLE ii 0 MU TIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS-15'C/7' ya TYPE OF CASING: p STEEL /t(F VC 0 OTHER: <br /> a VAPOR'r Q MUD ROTARY DEPTH OF GROUT SEAL �"3/TR£MIE TYPE TO BE USED: �UGERS a HOSE j <br /> a AIR SPARGE!OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: es Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30 <br /> ©SOIL BORING 17 HAND AUGER GROUT SPECIFICATIONS 3"��Ie Q �� 9y S C0-&'✓f <br /> a OTHER: 0 OTHER APPROX.BORING DEPTH S� BOLTED TRAFFIC BOX or a 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 I�certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County (Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x_l J/-- -- Title/Company <br /> Print Namelf Y���� Date /-l7 6,- <br /> �� DEPARTMENT USE QNLYAm� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ��-� <br /> 3t5"�t' Z <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued—fir Area <br /> Grout Inspection By Ate Final Inspection By <br /> Destructionlinspection By Dat <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> Cr S R D Q <br /> C-57 ' WC -WAIVER C-57 Letter of Authorization to sign pertnitV„Encro ment dor40Cr . <br /> EHD 29-02-001 <br /> 6122104 I° V <br /> � q <br />