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aOPq aG SAN .10AQUIN COUNTY 1,! p C <br /> ENMONMENTAL HEALTH DEPARTMENIR r` � SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 ITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sigOV. I /leh� 200 UNIT IV <br /> EI��1t/iR0iVr5:1EIVT ;fir H <br /> WELL PERMIT APPLICATION 1-1ERMIUSE9VICES <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 <br /> nTitle,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assesso <br /> Well Location <br /> 5%+9 I*F"yt� e:l— Cross Street (Ott 5tMe,+ City 5ay*Q Zip 95304 Parcel#is <br /> Property <br /> Owner Mr. SQcrtj Moore* Address City Zip Phone# <br /> C-57 Contractor N Address `t `,�t City Lic# Phone <br /> Consultant/Sub Cntr En, Address W2--` `� PuMeS&%0. City Lic# Phone <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 19 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> �]c WELL# M W— k ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING JKHOLLOW STEM DIA.OF BOREHOLE [:1S" MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> C <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS ,Y—k• +0 TYPE OF CASING:❑STEEL;%PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 56-f+ TREMIE TYPE TO BE USED❑AUGERS M HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:0 Yes ❑No (NOTE:MAXIMUM FREIE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS Por+1 C%n8 C�Yr*vl:11 T <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH sof <br /> BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDO TOR ASING PROPQSED (if YES,list specfications in comment section) <br /> COMMENTS: PYeVQ11t' c_OVl'tam�%Y10. OII'1, con � r ca�InCl :!OCOM 521 below s(,trF +� st�rQ;Lce <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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. <br /> Signed Title/Company 5t6&F G eo I oq i b-- N'.+h 6u <br /> Print Name E rI KI G reieYl e Date 12.t 11) <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> SR# <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />