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P '!" Lan Joaquin County FILE COPY <br /> a <br /> i Environmental Health DepartmentWIWIGATION <br /> SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> P' (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehA!ti;Y 0 2 .20ot UNIT IV <br /> Well Permit Application Em�JRO V <br /> 'I --;7 _ PE-Rol UE T HEATH f o et a <br /> REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED RVICES 5 �Q-rxJ <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 Location S- "� ,"'" Cross Street(X.1` vI�ar1 City C Zip Parcel# ;Z O 9 —,5/, O— <br /> CA- <br /> Owner-:2i;C L I C /►A A e 4'A�dress O 9!PROPERTYU s. �arl C <br /> ' t JCc—'Zip l�� hone# ZZ �— <br /> l�l� T�6lo �•O-a - ty Q,-oV 4--Zp 43 6Uc#�� Phonef�U —Ck9 <br /> C-57 Contractor /� Address o X �0 4 3 Ci <br /> (17 !<ol� CQ� 1���aSkn / ��Zla- ZloO <br /> Consultant/Sub Cntr ra� Address City ic# Phone# p <br /> 0 r ii SCS��� �� 1ilk-1-/6hG2�& <br /> GIS Coordinates:X � 4 �2 Y /2 1 32 eo Township ' ` Range Section <br /> WORK TO BE PERFORMED, <br /> p NEW WELL/BORING CPT,GEOPROBE,HYD OPUNCH, HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> >OIL BORING# 1,X— h �{!� 0 OVER-BORE. DIAMETER <br /> 0 WELL# (/ 0 PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 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 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0�NNo��(NJ/OTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> "`4 <br /> CI SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 0 n ; <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH (0 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 Ord ce ,mutes and Regulations, and all applicable California State Laws. <br /> Signed Title/Company <br /> Print Na ✓1�� ,cam� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: d <br /> Application Accepted By Date Issued S- 72 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> sR# <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encr c�doc-4zcj� <br /> GL7T1�011�11l11 <br />