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4Ik <br /> 'San Joaquin County <br /> Envinmental Health Department © TE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202GATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sigov.org/ehd MA I 0 2005 UNIT IV <br /> Well Permit Application ENVfRON <br /> &IENT HEALTH: <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT <br /> /SERVICES <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 9-1195.3 and the Standards of San <br /> �Jo�aquin County Environmental Health Department. 1 <br /> WELL Location l ) 7� Cross Street ' �- �l'' City Leel Zip S1�f!1 parcel# rs <br /> Assesso <br /> PROPE rTY - _ <br /> Own ery _ r�G�i Address r�J �C J. I <br /> ll.tY p � / Phone# , <br /> C-57 Contractor vat eAddress 9 e CityJ�Zip -fix Liw# k Phone# 6 <br /> Consultant 1 Sub Cntr Address City _ Lio# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> kNEW YVELL 1 BORING ,CP ,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER*) g DESTRUCTION (choose type below) <br /> JLSOIL BORING# g OVER-BORE. :DIAMETER <br /> g WELL# g PRESSURE GROUT <br /> g*Other GROUT SPECIFICATIONS <br /> COMMENTS: i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING g HOLLOW STEM DIA.OF BOREHOLE t g MULTIPLE CASINGS 1]MULTI-LEVEL .WELL CASING DIA: <br /> it <br /> g EXTRACTION g AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: g STEEL g PVC g OTHER: ~ <br /> g VAPOR JMUD ROTARY DEPTH OF GROUT SEAL I j, TREMIE TYPE TO BE USED: g AUGERS g HOSE <br /> g AIR SPARGE!OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: O Yes Ao (NOT • MAXIYUM FREE-FALL DEPTH IS 30') <br /> g SOIL BORING g HAND AUGER GROUT SPECIFICATIONS <br /> g OTHER: g OTHER APPROX.BORING DEPTH [ BOLTED TRAFFIC BOX or ,g STOVE PIPE <br /> is <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) f <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 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 Regu tions, and all applicable California State Laws. <br /> Signed x TitlelCampany r" <br /> Print Name l Date 3 r <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADD SS* 'h <br /> WORK PLAN DATED: Y9S <br /> Application Accepted By : Date Issued Area <br /> Grout Inspection By--:2n Date 3 Final Inspection By Date k <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 /> I <br /> 2•°I l `1 `� 2t �� s SR# t s5 <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 /> I <br />