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San Joaquin County <br /> _ Fvironmental Health Department IL ECof <br /> ITE <br /> 3rd Floor, Stockton, CA 9520 1 <br /> 304 East Weber Avenue,t <br /> ': .. 1t� �Fax: 209 468-3433 Web: wvw.sjCrov.org/ehd C ENV1ROf � ( � � UNIT IV <br /> QP . PER��IITISERVICE Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ication 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 /> .,uin County Development Title,Ch -1115.3 and the Standards of San Jcaquin County Environmental Health Department. q _�v _o <br /> ,,� /�� Assessors Z0 <br /> rFLL Location z L' 1 s' M+ -toss tet W, City c _Zip �• Parcel# — <br /> 0PERr1, 9%G �, Mc ifT�GkCity� a7p<t�Zip T-5-33�Phene# z-6cj— �3(0� X33 <br /> ier -Ado It ,`�J— /`�—Address Z I �-Q _ �f l <br /> mo,e-11 4-1, 47 Sc n, �Qi.fYn OrD (ter ! Z� J�O -✓ruy <br /> 57 Contractor ���Urto_ Address 2dia �}"d���+c�Ave� City i Zip r��ic# Phone, <br /> ��r <br /> isultant/Sub Cntr C 1�- i` ^ �A,P -qtr✓Address(ci�Zo ,�vClnk' tY�!ras.` Lic# Phone# /�J <br /> :5 <br /> ?'7 9 _ i � <br /> t' Coordinates:XJ �y 3 Z Y � Township ZS Range Section <br /> 11,jRK TO BE PERFORMED-, <br /> ,KNEW WELL/BORING (CPT,GEOPROBE,H DROPUNCH,HAND-AUGER,OTHER') Q DESTRUCTION (choose type below) <br /> ,kSOIL BORING# G ' ( rc Yj??, - 4'S Q OVER-BORE. DIAMETER <br /> Q WELL# r/i<� bC�,'/? Q PRESSURE GROUT <br /> Q'Other GROUT SPECIFICATIONS <br /> 'OMMENTS: <br /> ?E OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 10NITORING Q HOLLOW STEM DIA.OF BOREHOLE 2-g' Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS vi �� <br /> f VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL n %� TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q No�(NOT �MAXIMUM FREE-FALL DEPTH IS 30') <br /> KSOIL BORING Q HAND AUGER GROUT SPECIFICATIONS BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> I OTHER: Q OTHER APPROX.BORING DEPTH Q <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> 'OMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. �b�s <br /> Title/Company -5 -� 7 <br /> Signed x___ � j <br /> kCIi1�� Date ` 0 <br /> ?tint Na �'"^ r -e'er <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> !FORK PLAN D116y <br /> ED: �� 7-00 Area <br /> Date Issued g <br /> \pplication Accepte <br /> 3-( -DS <br /> ;rout Inspection By <br /> Date Final Inspection By Date <br /> )estruction Inspection By Date <br /> :OMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> C.ttti 3-1 SR# g� <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encr Ment doc—P.a �`'� <br /> curl')O_Msnt <br />