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San Joaquin.Countyf IL E APY <br /> MIAY 1 3FAtironmental Health Department SITE <br /> t <br /> #304er Avenue,3rd Floor, Stockton, CA 95202MITIGATION <br /> ENMR �'1`ax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> oPER <br /> 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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Locationross Sues Zip!25�,)d Parcel# <br /> PROPERTY .>,�,��,�� ,,J /J� )�� p <br /> Owner � _ "� Address 147 /l7"r^7'v" /���Gily Zip/T&Phone# O J Z / x <br /> C-57 Contractor�,S/G/- � ���p�/� Address�W U,�G Lir City L_Zip�4"# Phone `� <br /> Consultant/Sub Cnt (�/l��r-n`d� Address.WLC'rh Wy« Cil Fri Lic# Phone# <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> )WEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTRUCTION (choose type below) <br /> Q SOIL BORING s // Q OVER-BORE. DIAMETER <br /> WELL#_ * Q PRESSURE GROUT <br /> /Q Other_� y1 ' GROUT SPECIFICATIONS <br /> COMMENTS: — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING MOLLOW STEM DIA.OF BOREHOLELr'Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS t�TYPE OF CASING: Q STEEL­rVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL✓'' TREMIE TYPE TO BE USED: AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes )(No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS Q/� C�✓�• — <br /> Q OTHER:_O OTHER APPROX,BORING DEPTH (S2c.?- 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 /> ��� <br /> County Ordinances, Rules an gulations, and all applicable California State Laws. <br /> Signed x Title/Company ' // <br /> Print Name ✓ '--� Date—z-7/z//&5 <br /> DEPARTMENT AE ON"Y <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: i <br /> 1 /a/ <br /> Application Accepted By Date Issued ��/�O S Area v <br /> Grout Inspection By __Date Final Inspection B -. ale <br /> Destruction Inspection By Dale <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AIG# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED 11 CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> ,Z SR# <br /> C 57_V WC WAIVER_ C-57 Letter of Authorization to sign permitZ Encroachment doc <br /> 6122/04 EHD 29-02-001 O <br />