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tkjvw�l vv., <br /> 14400, <br /> 't'`'`i" SAN JOAQUIN COUNTY <br /> y. • ,y. <br /> ENVIRONMENTAL HEALTH DEPARTMENp � TE <br /> 600 East Main Street,Stockton, CA 95202-3029f nCATIYJ <br /> ./ Telephone:(209)468-3449 Fax:(209)468-3433 Web.Www.sjgay.orq(ehd <br /> `UNIT IV <br /> WELL PERMIT APPLICATION 4 � - <br /> .r NON-REFUNDABLE PERMIT EXPIRES i_YEAR FROM DATE IfNVIRONMENT HEAL � <br /> Application is hereby made to San Joaquin County for a permit to construed and/or install the work described. This application is made In compliancewith San <br /> Joaquin County Development Title,dtapler 9-1115.3 and the Standards of San Joaquin County Environmental Healfh Department. <br /> Welr �J� Assessors <br /> Property Icatiort � $. ✓ EkYe� Cross Street �_4' City � Zfp`� 0r Parcel# /7S �J�«0 <br /> Ower fes /+ I Ir Address® /G1<�a���45-0- 4 City.��r/a0 mid► Zip�y Phone# �.?�» x'3:3-'/S'� <br /> �. t <br /> C-57 Contractor __ Gg� Address Wo '00Glr el"'r� City� � Lic Phone -'z7e'd <br /> ConsultantiSubCnt s1llitM NAddressgaV2 /(!2! City 'Apl Lic# Phone 4 P-3 <br /> am GIS Coordinates:X Y Township Range Section _ <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORINC,(CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) JADESTRUCTION(CHOOSE TYPE BELOW, <br /> [I SOIL BORING# ❑OVER-BORE DIAMETER <br /> Gl WELL# ❑PRESSURE GROUT <br /> ow 171'OTHER / GROUT SPECIFICATIONS <br /> COMMENTS: I?P. GZ M na e <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �KMONITORING HOLLOW STEM DIA.OF BOREHOLE �� <br /> ��._ ❑MULTIPLE CASINGS 0Mt1LTl-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMCRIORIVEN CASING THICKNESS TYPE OF CASING:d STEEL 0 PVC ❑ OTHER <br /> �.+ [I VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS(]HOSE <br /> ©AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH Is 30') <br /> ❑SOIL BORING ❑HAND AUGER_GROUT SPECIFICATIONS <br /> r _ <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH BOLTED TRAFFIC BOX OR Q STOVE PIPE <br /> COMMENTS:��-,&!31 ft f lrf r� t�Ny Cn$IiJCjPRQPO$ED V,y` (fYES,IiSt6(13t1(8lipnSktCOTMCTlSft(i01) <br /> �. NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that t have prepared this application and that the work will be done t accordance with San Joaquin County Ordinances,Rules and <br /> ..r Regulations,and all applicable California Laws. <br /> Signed e Title/Company G'A'S 1�� <br /> Print N2:ne ev <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FIL DDRESS: <br /> r WORK PLAN DATED: <br /> APPLICATION ACCEPT BY _ DATE ISSUED AREA j <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> r DESTRUCTION INSPECTION BY DATE 5 ) f /� _ <br /> COMMENTSICONDITIONS: 1 af� ,�ee'ISI'/ l�iir_w{ 6 (3 , �yvL l?.: 7'te(ritn. ��f -r'.�L.rSLf�f��d4 <br /> ACCOUNTING ONLY: AID# _ _ FAC_# _ <br /> PE CODES FEE INFO AMT REMITTED CHECK# �- RECV'D BY DATE PERMiTJSERVtCE>f INVOICE <br /> C 5/ WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> $/�{ _ WELL PERMITAPP <br /> r <br />