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Joaquin C� unty <br /> Environmental Heald Department ( SITE <br /> < 304 East Weber Avenue, 3rd Ftoor Stockton, CA 95202 <br /> ATION <br /> (209)468-3449 Fax: (209)468-3433 II eb: www.sigov.org/chdOC � IT IV <br /> Well Permit Appt cation <br /> ► sR I <br /> NON-REFUNDABLE PERMIT EXPIRES 1 Y.AR FROM DATE ISSUED �����'�Rr/rNE,��rf,� <br /> ' t^s deIn compliance with San <br /> County for a <br /> permit to construct andlo install the work described. This.applicatio <br /> Application is hereby made to San Joaquin C tY p <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Jr agUn Coun Environmental Health Departmen. <br /> ,7 Assessors <br /> WELL Location r `` ' " s Street city- ZipqParcel# Q� <br /> PROPER 6( C glif /' Zip Phone# <br /> Owner dress <br /> I <br /> C-57 Contractor ` Address.- . ! City Zip LickPhone# <br /> /���.� d s Cit <br /> Y ;? ]Phone# <br /> Consultant I Sub Cntrr7c ? <br /> GIS Coordinates:X Y Township6� Range 5ectioh <br /> 'pIl <br /> WO K TO BE PERFORMED: <br /> EW LL!BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-) JGER,OTHER*)' p DESTRUCTION (choose type below) <br /> 501E BORING# [�OVER-BORE.-DIAMETER—_ <br /> 0 ELL# Q PRESSURE GROUT <br /> *OtherGROUT SPECIFICATIONS <br /> k <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPEL IFICATIONS - lV7`-F- <br /> r 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE "`�nn MULTIPLE CASINGS 1]MULTI-LEVEL WELL CASING DIA: . <br /> 0 EXTRACTION 0 AIR HAMMERIDRiVEN CASING THICKNESS✓ . TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR D MUD ROTARY DEPTH OF <br /> GROUTS : REMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE!OZONE USH POINT(GP or CPT)GROUT SEAL PUMP [ YesA No NOTE- MAXIMUM FREE-FALL DEPTH IS 301) <br /> IL BORING O HAND AUGER GROUT SPECIFICATI NS <br /> SOLIED TRAFFIC BOX or 0 STOVE PIPE <br /> U OTHER: a OTHER APPROX.BORING D,pTH �tJ 0 BO <br />` CONDUCTOR CASIN11 PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: 5 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCES$11AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE' SQUIRED FOR INSPECTIONS. <br /> I;hereby certify that I have prepared this application and thl t the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applica le California S to Laws.. <br /> Signed x j I r7 <br /> tle/Company <br /> Date <br /> Print Name i Ai <br /> DEPARTME IT USE ONLY <br /> i SITE MAP IN UNIT'IV FILE,ADDRESS: <br /> Y WORK PLAN DATED: <br /> .� bate Issued i� v Area—L� <br /> Application Accepted By ate Z <br /> Dale 2��I. Fina!Inspection By <br /> D <br /> I` Grout Inspection By <br /> Destruction Inspection By Date <br /> ik COMMENTS I CONDITIONS: . <br /> ACCOUNTING ONLY: AID# AC# <br /> E PE CODES FEE INFO AMOUNT REMITTED CHECK# EC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> SR# <br /> E b 3 37 y-o� ov. <br /> j <br /> C-57_ WCC WAIVER= C-57 Letter of Authori tion to sign permit Encroachment doc� <br /> FHD 29-02-001 <br /> 6/22/04. <br />