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U1/13/2016b 14 3t 2094bUJ4.33 FIFTH FLOOR PAGE 03 <br /> San Joaquin County SITE <br /> Environmental Heath Department <br /> >n � 344 East Weber Avenue,3rd Floor, Stockton, CA 9� D ITiGATlON <br /> (209)468-3449 Fax (209)469-3433 Web www sigov ���� UNIT IV <br /> � <br /> fia Well Permit Application <br /> JAN ? 7 7.005 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED�hr de in compbance with Son <br />,ppi,cabon,s hereby made to San Joaquin County for a permit to construct andlor install the work des i 1�1 <br /> oaquin County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County En�,ron SER Assessors <br /> 3o t 5oe P°'"^b� Par -02-,D- <br /> WELL <br /> 02.0-1 <br /> WELL Location t- Cross Street r C,ty )2 ziP 7- <br /> PROPERTY eti'")alo'` �K�Q��s c try. 07�!40 Phone#Owner !�+ ,-o Addrass�< ZR � S7 �5 �� �7;S D14J7t e�--- <br /> C-57 Contractor ddress <br /> +^-�✓ a ►tv.Ycv� Address " �•5-�` CityLic#------Phone# <br /> Consultant!Sub Cnt <br /> G15 Coordinates X <br /> Y Township Range Section <br /> WORK TO BE PERFORME.o DESTRUCTION (choose type below) <br />•[IlNEW WELL/ BORING CP GEOPROBE HYDROPUNCH, HAND AUGER OTHER'S OVER-13OP,E DIAMETER <br />��`` a SOIL BORING tr _ R� � 0 PRESSURE GROUT <br /> 0 WELL# GROUT SPECIFICATIONS <br /> 0-Othor <br /> COMMENTS <br /> TYPE. OF Lt INSTALLATION TYPE CONSTRUCTION SPI=CIFICATIONS r- <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE 2" [l MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> TYPE OF CASING 0 STEEL p PVC 0 OTHER <br /> []EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TREMIE TYPE TO BE USED' []AUGERS Q HOSE <br /> (] OR [I MUD ROTARY DEPTH OF GPOUT SEAL <br /> PARGE!OZONE PUSH POINT(GP or t�GROUT SEAL PUMPED )Yes []No (NOTE SMA MUM ALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER APPRO GROUT BORING <br /> i5S—' „.G� 'tBi!'TBOLTED TRAFFIC BOX or []STOVE PIPE <br /> []OTHER f,-..,...,,..�0 OTHER APPROX BORING pEPTH CI <br /> CONDUCTOR CASING PROPOSED (,f 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 /> I hereby certify that I have prepared <br /> and a I ppl cable the <br /> fore awill <br /> s ate Laws accordance with San Joaquin <br /> and <br /> County Ordinances, Rules Regulations, <br /> TjtlelCompany <br /> Signed x <br /> Date <br /> print Mame <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: J <br /> Date Issued <br /> Application AGceptad t3y Date <br /> Grout Inspection By <br /> Date Final Inspection By <br /> Destruction Inspection By ate <br /> n -S !A ! <br /> COMMENTS!CONDITIONS <br /> CCOUN7ING ONLY AID# FAC# <br /> CCD B DATE PERM I71 SERVICE REQUEST# INVOICE <br /> ODES FEE INFO AMOUNT REMITTED CHECK# RE <br /> SR# <br /> Sol- <br /> 55 . 00 7-11 p0 1 �fD <br /> C-57 WC -WAIVER C-57 Letter of AUtho ze on o sign permit Encroachment doc <br /> EHD 29.02-001 <br /> 6122/04 <br />