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IREC YED <br /> - <br /> Pq.Ufly SAN JOAQUIN COUNTY .- <br /> a <br /> jA 1 5 ?OLS <br /> e ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029VIR014M 1111'Hi-AMTIGATION <br /> Telephoner(209)468-3449 Fax:(209)468-3433.Web:www.S' �:pI <br /> / r_e UNIT IV <br /> :�.�"� <br /> 4�f�04z� - <br /> WELL PERMIT APPLICATION <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 Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ry Assessoes <br /> Well Location ]y t J. L rn.,r Lrn c_ Cross Street r s V� City rn� Zip IS-376 Parcel* 7-7­-,33 -c7 <br /> Property <br /> Owner Si Address /�OtD1?rf 7�-� Lfin City .!'��,n�-�4.� Zip_ Phone# (Zc.P 6, --5 414 <br /> C47 Contractor V,'ro �— Address 5��'2� ,«��,�co dila .. City c,�11�� Lic# O S%LJ Phone C`3z-S�. 24'IYlQ <br /> ConsultantlSub Cntr;�9,u�Six.a .t- ;.Address -0ell�- C± Shz 2-W City Lic# VAG-Phone <br /> GIS Coordinates:X 1 ZI o Lr '�;✓ 'Y `�5 13 ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ONEW LL BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# V H- 4rcw 80­6 ❑OVER-BORE DIAMETER <br /> WELL# ❑PRESSURE GROUT <br /> I <br /> El'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> i TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [I MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE � � ,D MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> I 0 EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL 0 PVC © OTHER <br /> ©VAPOR ©MUD ROTARY DEPTH OF GROUT SEALrJ TREMIE TYPE TO BE USED El AUGERS❑HOSE <br /> 0 AIR SPARGE/OZONE rNrPUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes No (NOTE:MAXIMUM FREE-FALL DEPTH Is 30') �+ <br /> p SOIL BORING 0 HAND AUGER .GROUT SPECIFICATIONS YJ¢ff" �n'� <br /> [I OTHER: Q OTHER: APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX OR El STOVEPIPE <br /> CONDUCTOR CASING PROPOSED o. (if YES,list specificattons 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 <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,andall plicable Ca' rnia Laws. <br /> j Signed �" TitlelCompany <br /> Print Name o - r v Date <br /> DEPARTMENT USE ONL <br />! SITE MAP IN UNIT IV FILE,ADDRESS: <br />!� WORK PLAN DATED_ f `� �I 'LA.-7O� <br /> i APPLICATION ACCEPTED 8Y DATE ISSUED / D AREA <br /> rr GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> 441 <br /> 1 DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV D BY DATE PERMITISERVICE X INVOICE <br /> a1 81_ 6L~ ml(arm ! D S SR#[S�1Sb <br /> C-57. - WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PE MIT ENCROACHMENT DOC <br /> EHD 29-01 1115707(WEB) WELL PERMtT APP <br /> 3-2t,�� <br />