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air r San Joaquin County <br /> �` cn Environmental Health Department SITE <br /> ^ ' 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> ' oar P Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 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 Title,Chapter/9 11 5.3 and the Standards of S n Joaquin County Environmental Health Department. <br /> Assessors <br /> /J <br /> WELL Location �b- u'� Cross Street of <br /> City Zip Parcel#PROPq <br /> Owner Address <br /> City_4,"_- -ZiPhone#az?c1 q�O�(� <br /> C-57Conlractor Addresr�l�C� 9/ City_k Zip Lic�x�Phonelle�b��o �/�Oc7 <br /> Consultant/Sub Cntr I - Addresses �_)�,lntli�ECity_5X ✓ Lic# �- Ph,ne#Z-y14y//wo}A1��� <br /> GIS Coordinates:X _ ,Y ,Township Range a l�n_C_ ,• L, y <br /> WORK TO BE PERFORMED: L GGTu/fvuf <br /> p NEW WELL 1 BORING (CPT, OPR B HYDROPUNCH,HANG-AUGER,OTHER ) ,DESTRUCTION (choose type below) <br /> SOILBORIN(i# r tr I 11 VER-BORE. DIAMETER_,_ <br /> 3 /JELL# r jy(��Y PRESSURE GROUT 1 <br /> Q*Other ' rrr a GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE_ Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA:_ <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGEI OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER:_n OTHER APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX or Q 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 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 -" yy Title/Company <br /> Print Name S —Dis <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: Q <br /> Application Accepted By - Dale Issued S A u <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Dale <br /> COMMENTS/CONDITIONS: 7 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INAMOUNT REM!1,TTEDj CHECK# REC'O BY GATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> C-57_ WC -WAIVER_ , C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> z <br /> EHD 29-02-00 I a <br />