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SAN JOAQUIN COUNTY <br /> <` MENVIRONENTAL HEALTH DEPARTMENT SITE <br /> Iy <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: WWW.S ov.o � ION <br /> WELL PERMIT APPLICATION t �'— <br /> �Q� .N �, � Zola <br /> �� lljj <br /> VNON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F�A,LTrl <br /> C �,II NT H�Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applic�lt I Mjbbith San <br /> Joaquin County Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Depa4,vvt%u� <br /> m <br /> Assessor's <br /> Well Location/ ross Street L City Zip�� Parcel# <br /> Property !1 <br /> Owner��� 0,la Address 7 ��y `���vrJ�f/Jf/ ,City��� ��� Zip�Phone# <br /> C-57 Contractor Address, STZ��% � City /� Zip!�,!!I -Lic#2=gam Phone <br /> ConsultanUSub Cntr Address / City Lic# Phone <br /> GIS Coordinates X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER') ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br /> ❑ SOIL BORING# E] OVER-BORE DIAMETER <br /> WELL# /yJ f� - � ❑ PRESSURE GROUT <br /> 'OTHER GROUT SPECIFICATIONS <br /> ❑ EXPLOSIVES DETONATING CARD <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING X HOLLOW STEM DIA OF BOREHOLE � ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:E / <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS' `& TYPE OF CASING: ❑STEEL Jr PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL .��TREMIE TYPE TO BE USED❑AUGERS❑ HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED❑Yes <br /> //❑No <br /> (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> [1SOIL BORING ElHAND AUGER GROUT SPECIFICATIONS/r <br /> ❑OTHER ❑OTHER: APPROX.BORING DEPTH ��� J�BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED , 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 /> 1 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 41 applic ble California Laws. <br /> Signed Title/Company , <br /> Print Name Date <br /> tt DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS/ 1 2 r7 6 MaA.r,L L - ,.- <br /> WORK PLAN DATED: U v Z ) 7-0 01 <br /> APPLICATION ACCEPTED BY DATE IS UE a� D AREA C' <br /> GROUT INSPECTION BY FINAL INSPECTION BY U DATEZ 16 <br /> DESTRUCTION INSPECTION BY DATE p /- <br /> CDMMENTS/CONDITIONS: C SvU S Jw wt�1 Z � <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# I INVOICE <br /> Z 30 I / �'2 I 0 SR# DDs92q <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIG PERMIT ENCROACHMENT DOC <br /> END 29-01 10/28/09 _ WELL PERMIT APP <br />