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SAN JV-AQU:NK COUN <br /> ir-NviRONMiENI AL 'HEALTH DEPART[O ' SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Teiepnone: (209)468-3449 Fax: (209)468-3433 VVeb: www.sjqov.org/eho UNIT IV <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 /> Assessor's <br /> Well Location Cross Street City Zip Parcel# <br /> Propertycity P Zip Phone <br /> Address S S, <br /> Owner <br /> city Phone_ <br /> C-57 Contractor Address Lic# <br /> !Ne� )f 41, :&y P.lk Lic#—Phone <br /> Consultant/Sub Cntr Address <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYOROPUNCH,HAND-AUGER,OTHER-) El DESTRUCTION (CHOOSE TYPE BELOW) <br /> E] OVER-BORE DIAMETER <br /> F-1 SOIL BORING# 0 PRESSURE GROUT <br /> M WELL# GROUT SPECIFICATIONS <br /> F>I.*OTHER T-e�n ev <br /> COMMENTS: U-S V-` V-7 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ED MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE El MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> — <br /> 0 EXTRACTION r-1 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:[3 STEEL C]PVC C1 OTHER — <br /> El VAPOR C1 MUD ROTARY DEPTH OF GROUT SEAL TREME TYPE TO BE USED El AUGERS EI HOSE <br /> r-1 AIR SPARGE/OZONE Ek PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:0 yes [I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> r-1 OTHER: El OTHER: APPROX.BORING DEPTH 4 E]BOLTED TRAFFIC BOX OR El STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: V <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 /> Title/Company <br /> ,> tAS &,):V%;AVVJnY�j <br /> Signed <br /> —Date 7 <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED B DATE ISSUED. 1) AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY�A DATE j[E310 <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 /> C-57 WC -WAIVER _C57 LETTER OF AUTHORIZATION TO SIGN PERMIT� ENCROACHMENT DOC <br /> WELL PERMIT APP <br /> EHO 29-01 11/5/07(WEB) <br />