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San Joaquin County %Vol <br /> Environmental Health Departni ,i't SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov6Fg/ehd , UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE tSSUED ;.' <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 /> 1 / y p523` Assessors <br /> WELL Location TY e�`l� Cross Street / city Zip? 7 lfJ Parcel# <br /> PROPE �' <br /> Owner (( l Address l/A�"rt�T)/�t�,b�nr_Lkb ityd�Zip]7�Phone#�'— ,300<D <br /> C•57 Contracto ""6t d �J"(Address L� KUaA cityhk&e�n Zip(' 53 Lic#06 I`� hone#�_6- �3' oD <br /> LV <br /> Consultant/Sub Cntr kttA �n�i tC ch/Address )(` City Q Qtd Lic# lg f Phone# 'Mo•951-01':7-Lt <br /> GIS Coordinates:X Y Township Range Section Ul <br /> WORK TO BE PERFORMED: 41- <br /> ,19NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) Q DESTRUCTION (choose type below) <br /> SOIL BORING# c pT— I Q OVER-BORE. DIAMETER <br /> Q WELL# Q PRESSURE GROUT <br /> Q*Other GROUT SPECIFICATIONS <br /> COMMENTS: _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE 2" 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 c� TREMIE TYPE TO BE USED: Q AUGERS CHOSE <br /> Q AIR SPARGE/OZONE jkPUSH POINT(GP or CPT)GROUT SEAL PUMPED: AYes Q No (NOTE: MAXIMI FREE-FALL DEPTH IS 30') <br /> JrSOIL BORING Q HAND AUGER GROUT SPECIFICATIONS '�tst DcZ�1 ff tri <br /> Q OTHER: Q OTHER APPROX.BORING DEPTH by 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 /> 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 x01&. ` n^ Title/Company U�% CSC 2) t c51 C VIII GI�(��m <br /> Print Name Date Z0—/;v 0 Is <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 5�Yz 3j 1 i= S-jyeet <br /> WORK PLAN DATED: <br /> Application Accepted By i�G� C�td Date Issued �U�Zgle, Area ws3 <br /> Grout Inspection By C Date // Final Inspection By �G� Date <br /> Od // D9 CSS <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3Su3 5',6 4Z7y,vc 7896) Z. C,iiJiit SR# QC) gg5 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EH 29-02-001 <br />