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PQ�Iti. SAN JOAQUIN COUNTY <br /> r ''a ENV RONMENTAL HEALTH DEPARTM SITE <br /> �y t ��I� D <br /> 600 East Main Street, Stockton, CA 95202-3 —' ITIGATION <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.org/ehd UNIT IV <br /> e0R� 2010 <br /> WELL PERMIT APPLICATION <br /> p,r) ENVi1�UNt�ILN F HEALTH <br /> d\ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE I ItSERVICES <br /> C. <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 Standar sZofSanJoaquin County Environmental Health Department. <br /> / Assessor' <br /> Well Locationim i ling' p�1 U tG Cross Street City Zip �D Parcel# <br /> Property <br /> Owner � LLIAddress v4z , _ r/ / <br /> City�.9V)7��� Zipej/Z!�Phone# <br /> C-57 Contractor IAI D Address City Zip!ft&Lic# /�/Phhonnevv,, <br /> ConsultanUSub Cntr Address Cityis# Phone��t/`glLl`GZLU <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 BORIN # ❑ OVER-BORE DIAMETER <br /> J$(WELL# /�f� ���d �X ❑ PRESSURE GROUT <br /> F1*OTHER GROUT SPECIFICATIONS <br /> ❑ EXPLOSIVES DETONATING CARD <br /> COMMENTS. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> X MONITORING HOLLOW STEM DIA OF BOREHOLE I // ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS A YD TYPE OF CASING ❑STEEL XPVC ❑ 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 ❑ No (NOTE: MAXIMUMM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS � lFh�l�/r/� <br /> ❑OTHER _ ❑OTHER: APPROX.BORING DEPTH BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED of YES,list specifications in comment section) <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 Law <br /> Signed Title/Company Z2 — <br /> Print Name Date__%/// <br /> DEPARTMENT USE ONLY T' <br /> SITE MAP IN UNIT IV FIL ADDRESS (Alk-X- <br /> WORK PLAN DATED: I & Zr0 �d <br /> APPLICATION ACCEPTED BY DATE ISSU D 1 D AREA / <br /> GROUT INSPECTION BY FINAL INSPECTION BY U DAT 0/1C` <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: nv <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMit 1T REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 11Z-7 10 1 SR#,6V <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br /> 3A5,,03 'jII11' 3 <br />