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San Joaquin County _ <br /> Environmental Health Department SITE <br /> < 600 E. Main Street, Stockton,CA 95202-3029 <br /> MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> F Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 7 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 DevelopmElt Title.Chapter 9-1115.3 and the Standards of San Joaquin <br /> / ounty Environmental Health Department. <br /> Cos S �SPane/# <br /> WELL Location eetV � ({ ' Zsm <br /> Ar <br /> J� <br /> (�o l( o ir�i z; <br /> PROPERTY ( ( S / L j �ddrese �.�. c;ry pnone# 1�J <br /> I`, Ctiedr 55 PG (ae�s 3 3� city ro ' fetzip CA a toa }�r�ne# e�-37 /L <br /> C-57 Contra ctpr v L.7�u bil - )' o /� p <br /> Consultant/Sub Cntr Ate.•)rl SOL✓lJ Address (� lSu U' City t' �'�'Lic#1-/__ Ghone# I 1 �� �J <br /> I <br /> GIS Coordinates:X �' � � ,V ownship t Range Section <br /> WORK TO BE PERFORMED: <br /> OEWELL/BOR NG ;CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) D DESTRUCTION (choose type below) <br /> SOIL BORING# ?L 1-0 ;I 4,OCX tjvr vl-fz D OVER-BORE. DIAMETER <br /> D WELL# D PRESSURE GROUT <br /> D`Other GROUT SPECIFICATIONS <br /> COMMENTS: — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE/ D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL D PVC D OTHER: <br /> D VAPOR D MUD ROTARY //'' DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS D HOSE <br /> D AIR SPARGE/OZONE Nf PUSH POINT(GP oI;CPT)GROUT SEAL PUMPED: D Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING >sJ HAND AUGER GROUT SPECIFICATIONS <br /> U OTHER:— yh OTHER APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED_(if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFS TE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br /> I hereby certify that) 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 LawYss.� �p� <br /> Signed,z I NQ- Title/Company I�- 1��-""7 SQ <br /> 4� �a0 <br /> Print Nme <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IW FILE, ADDRESS, �8 2-1 r �4Je-�- - - <br /> WORK PLAN DATED: t <br /> Application Accepted By <br /> Date Issued <br /> Grout Inspection By —Date _Final Inspection By Date _ <br /> Destruction Inspection By- Date <br /> COMMENTS I CONDITICNS: <br /> ACCOUNTING ONLY: AJ D# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK* REC'D BY DATELPERMIT SERVICE REQUEST# INVOICE <br /> b�ZSa (, <br /> C-57_ WC=`✓AI9'ER_ C-57 Letter of Authorization to sign permit-t,— <br /> C-5 doc_ <br /> FHn 29-()2-nnlweh <br />