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"San Joaquin County <br /> Envi'Alnmental Health Department SITE <br /> �o 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> TV ECE#yTION <br /> (209)468-3449 Fax: (209)46$-3433 Web: www.sjgov.org/ehd �IV � <br /> Well Permit Application. MAS z <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This a P1It9W&i j@F,9npliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> i <br /> ` Assessors <br /> WELL Location 6 Cross Street n' City Zip J2�O Parcel# <br /> PROPERTY <br /> Owner / ��� Address W7,2- I)/ Vir-L":z—y"f tf f�� ip /q�y, '/()phone# <br /> C-57 Contractor— (I .1261AMe Address ,!&;_1V• Ci �: S : J <br /> tyZip 1 .�Lic# ��+hone# ti• —/G�. <br /> Consultant/Sub Cntr Address City Lic# Phone# <br /> GIS Coordinates:X - 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> PEW WELL I BORING ( PT,rpE PROBE, HYDROPUNCH, HAND-AUGER, a DESTRUCTION (choose type below) <br /> SOIL BORING# p OVER-BORE. DIAMETER <br /> WELL# ll PRESSURE GROUT <br /> p*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA,OF BOREHOLE_ .p MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: !ma'''r <br /> 0 EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS. TYPE OF CASING: a STEEL a PVC 0 OTHER: min <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL ly I TREMIE TYPE TO BE USED: 'DAUGERS 0 HOSE <br /> a AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes yNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30'). y <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS r4,j QjntA� <br /> a OTHER:_0 OTHER APPROX. BORING DEPTH BOLTED TRAFFIC BOX or a 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�ces, ules and Regulations, and all applicable California State Laws. <br /> Signed x i (! Title/Company <br /> Print Name i Date 3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,AD RE S: a 0 , <br /> WORK PLAN DATED: 3 111 5 J <br /> Application Accepted By Date Issued / S Area f: Z <br /> Grout Inspection By_'_771- Date .2 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: - <br /> _ it <br /> ACCOUNTING ONLY: AID# FAC# <br /> is <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 19901 � � 2�-l'�� `� 3 ( �s SR# y ).55 -7 <br /> C-57 WC -WAIVER C-57 Letter of Authorization-to sign permit Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />