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144* SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTM E <br /> j]�/]2LL; V �ITE600 East Main Street, Stockton, CA 95202-3 <br /> i` Telephone:(209)468-3454 Fax:(209)468-3433 Web:wwwslcloy.or /ehd ZO'0 UNIT IV <br /> WELL PERMIT APPLICATION <br /> NV'{ m'ORUtCES <br /> TH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAT Iii <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 0-1115.3 and the Stands of San Joaquin County Environm ntsl Health Department. <br /> Assessor' <br /> Well Location Cross Street City Zip f& Parcel# �1 <br /> Property �"f ��, <br /> Owner Address g�2<// A&N City if TBS r Zip Phone# <br /> C-57 Contractor Address City Zip Lic#=?,E Phone <br /> ConsuftanVSubCntr Address 00' City is# Ph <br /> one <br /> GIS Coordinates.X Y Township Range Section <br /> W K TO BE PERFORMED: <br /> WNEWWELLISORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BOR nC ❑OVER-BORE DIAMETER <br /> WELL#,(�( „( ❑PRESSURE GROUT <br /> *OTHER y GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF W9LL INST,A"TION TYPE CONSTRUCTION SPECIFNATIONS <br /> MONITORING 19 HOLLOW STEM DIA.OF BOREHOLE dig" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DtA: � <br /> ❑EXTRACTION O AIR HAMMERORIVEN CASING THICKNESS 6eA yD TYPE OF CASING:0 STEEL a[PVC ❑ OTHER <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL _TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> AIR SPARGE/OZONE 0 PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:0 Yea 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING O HAND AUGER GROUT SPECIFICATIONS Cr°�YFI�IA fX L�J 'r�taL <br /> El OTHER _ ❑OTHER: APPROX.BORING DEPTH 5, BOLTEC TRAFFIC BOX OR C STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,ibl specffwA lona in convnenI section) <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certHy that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulstlons,and all appllcabls Callromis <br /> Signed TitlelCompany ` <br /> Print Name Date <br /> / <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FIL ,ADORES& f �� I'K�-i1^ <br /> WORK PLAN DATED: 11, & 1 �0 <br /> APPLICATION ACCEPTED BY DATE ISSUED D AREA �t 9 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: S � <br /> ACCOUNTING ONLY: AID# FAC# <br /> -'E CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 3s,c! 8g ' ��" 2 T o� I 1 z7 /V S11#00 61';9'2 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2"I 10/26 } 1. WELL PERMIT APP <br /> 39r,03 } �S. r ,i <br />