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Pq�iN. SAN JOAQUIN COUNTY <br /> "'? ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> " ` 600 East Main Street, Stockton, CA 95202-3029 TIGATfON' <br /> .: [! <br /> Telephone:{209}468-3454 Fax:{209}468-3433 Web:www..s- IT 1V <br /> CrFOR <br /> :w WELL PERMIT APPLICATION JUS !r 7 cu,u <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE HEAV <br /> �pr �iance with San <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This ap }}V7� <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. A sessor's <br /> Well Loy <br /> ss Street City SZip g520�' Parcel# <br /> Property, <br /> (� Ice'�!��,I ! Zip g l Phone# 4-7'7-S-405: <br /> Owner Address City S i _ <br /> &9"-Address <br /> } C-57 Contractor 4a_ yUev l /In>1 t itY Q c I` Phone s <br /> Consultant/Sub Cntr Address g 37 City ,36, 4'` Q Lic# Phonez/1k77 Lam{ fit' <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION{CHOOSE TYPE BELOWI: <br /> F-1 <br /> NEW WELLIBORING(GPT,GEOPROSE,HYDROPUNCH,HAND AUGER,OTHER-) OVER-BORE'DIAMETER 12 AAe <br /> E]SOIL BORING# PRESSURE GROUT <br /> E]WELL# GROUT SPECIFICATIONS <br /> ❑"OTHER EXPLOSIVES DETONATING CARD <br /> I,� oar `b``+l•�-vrlNl �w r � z�-�,,� �ei'I� - . � � t,� <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPE IFICATIONS y <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE TMULTIPLF CASINGS El MULTI-LEVEL WELL CASING DIA: ; <br /> EXTRACTION ❑AIR HAMMER/DRIVEN' CASING THICKNESS TYPE OF CASING:❑STEEL VC ❑ OTHER <br /> P'6APOR ©MUD ROTARY DEPTH OF GROUT SEAL �{rj' REEMMIE TYPE TO SED�AUGERS❑HOSE <br /> ❑AIR SPARGEIOZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:9Yes El <br /> No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30) <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS _ <br /> c ❑OTHER: APPROX,BORING DEPTH ❑BOLTED TRAFFIC BOX,OR E3 STOVE PIPE <br /> El OTHER: <br /> CONDUCTOR CASING PROPOSED (if YES,list speci5cations 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 thatthe work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicajble�}Ca�lifornia Laws. <br /> Signed TitlelCompany <br /> l - <br /> Print Name WIV&am Date .2 a-) 0 <br /> I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE`,ADDRESS: 3 Z J• ���-- <br /> ! WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED Z �D AREA <br /> GROUT INSPECTION BY FINAL INSJPECTIO BY DATE <br /> DESTRUCTION INSPECTION BY H�-. DATE z7 Lly <br /> I CONIMENTSICONDITIONS: LoP S I.�B,b <br /> ACCOUNTING ONLY-. AID#.- <br /> P.E <br /> -PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> Soz 00, (00- - �w �fL "� a7a�ld SRS 6b <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br />