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wire „ <br /> 304 Gast Weber Avenue, 3rd Floor, Stockton , CA 95202Joaquin Cauinty <br /> Envixontmental Health Depart & T <br /> TIGATI0 <br /> •' f (209) 468-3449 Fax: (209) 468-3433 Web : wwwsjgov .org/ehd 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 /> Assessors <br /> WELL <br /> WELL Location 6 � o ' / yn4f r S4- ` Cross Street City 54cF &4­o71 Zip ySV 02Parcel# <br /> PROPERTY a69 � 9 <br /> Owner /arra. Em 4Ye nSrS �� C Address $/6 j vr� n .lode �l City �(h4s ZipyS�% Phone# S <br /> 3 .} � (687i Cc-sr <br /> C-57 Contractor GJoa �war � Fr J�j,x /D Address �, RbRb ;e 33 6 city 1216o Uty}z. Zip YS7 / Lic# Phone# 707- 3751- X.06 <br /> Consultant / Sub Cntr raTL 5556 Cia--r57r f. Address L , 041eA #2City '��e Lic#/ /✓ r`1- Phone# 269 - 5 7� q- 7796 <br /> GIS Coordinates: X.1 Y , Township I lJ Range G 1 Section - <br /> WORK TO BE PERFORMED: <br /> ANEW WELL / BORING (CPT, GEOPROBE , HYDROPUNCH, HAND-AUGER, OTHER*) g DESTRUCTION (choose type below) <br /> SOIL BORING # Ur r•{9iDOVER-BORE. DIAMETER <br /> 0 WELL # 0 PRESSURE GROUT <br /> *OtherGROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0,HOLLOW STEM DIA. OF BOREHOLE�4 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: p STEEL p PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: r;g.Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> Y ASOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> D OTHER: Il OTHER APPROX. BORING DEPTH 3S r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED AJ 6 (if 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 this application and that the work will be done in accordance with San Joaquin <br /> County Or/di/non!/c/e1s, Rules and Regulations, and all applicable California State Laws. <br /> Signed r. f ( 1C`'!I/ "J '�r Title/Company e/_ d ; C/- 6lrd /d� <br /> Print Name �p7'ytu Fl � !� ''759H Date USI f <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : too l� <br /> WORK PLAN DATED : ^ .' ' Z�q <br /> Application Accepted By � <br /> !.�]�-4�`' Date Issued 45-1-t-`t Area 36 t ( <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection B Date —��� <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK�1# REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> C- 57,�' WCC-WAIVER_ C-57 Letter of Authorization to sign permit,, Encroachment doc_ <br /> EHD 29-02-001 <br />