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.. ..;, SAN JOAQUIN COUNTY <br /> ENVIR�­,IMENTAL HEALTH DEPARTMEN . OtGATION SITE <br /> 600 East Main Street, Stockton, CA 95202-30 <br /> Tele hone: 209 468-3449 Fax: 209 468-3433 Web:vvww.s ofp > > NIT IV <br /> WELL PERMIT APPLICATION NIA Y. 2 2009 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE�SWENT HEALTH <br /> nIIT/SERVICES <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 Environmen I Health Department. <br /> pssessor's <br /> Well Location �� Cross Street O City Zip Vr . arcel# <br /> Property / ;/, <br /> I (�C Address City Zip< �� Phone# <br /> Owner <br /> C-57 Contractor ddres0 2 Cit Li PhoneNF— <br /> Address fCit e — <br /> (JL(V U <br /> Consultant/Sub CntrY is# Phon <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER, ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑ SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑ WELL# (" ❑PRESSURE GROUT <br /> F-1*OTHER GROUT SPECIFICATIONS <br /> COMMENTS:7i'L��,��s���"TLU'� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING RrHOLLOW STEM DIA.OF BOREHOLE _ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ra <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS <br /> �TYPE OF CASING:❑STEEL Z PVC El OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL rf TREMIE TYPE TO BE USED❑AUGERS O HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:;M Yes El <br /> No (NOTE: MAXIMUM FREE-FALL DEPTH IS 0') <br /> ❑SOIL BORING ElHAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OOTHHEERR:(�jy� APPROX.BORING DEPTH <br /> fD "� YrBOLTED TRAFFIC BOX OR [3STOVE PIPE <br /> NDU�T�04 DINg J/ 1y7`'V/ �Y tc,I( ti dLJns In comment section) <br /> COMMENTS: I �r�,L (L/ T <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 appli able California L s. <br /> Signed A <br /> Title/Company <br /> Print Name Date <br /> y� DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 350s7- / ��n <br /> WORK PLAN DATED:_ C UI�L-U✓C��_�GyO / v <br /> APPLICATION ACCEPTED BY <br /> - -wy DATE ISSUED S Z D'� AREA9 C1 <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 /> '�-qol 85- '?q- lgy2)-"7 2 o�! SR# oa'S-7387 <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 />