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SAN J OAQUIN TY <br /> ECOPMTE <br /> Q EN` ., ; <br /> _ JNMENTAL HFAL�li UEPARTNIE_, MI >f�lly <br /> 304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 �E� <br /> ~ (209)468-3449 •Fax:(209)468-3433• Web: Www.co.san joaquin.ca.us/ehd <br /> A4 a (j <br /> OCL/FO�� P � <br /> 2006 <br /> WELL PERMIT APPLICATION FORM SAN JO <br /> J�TT// /�►I �E�-� `I H E TH ON MI COON <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EALTH DE ARTTAL ry <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 complianceV$an <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> WELL Location /?7,qQLMJ� $ OR Cross Street - c. 'c Aj City v p Assessors <br /> �5 fzr kto Zi o�s__ Parcel# p <br /> cry _7 cu -MVD r <br /> PROPERTY Owner5tov-_A'7y;,) A[dddress /-� N• City _5fnc14fc)c, Zip 2 CIL Phone - <br /> C-57 Contractor Z�,y Addres 7�`�5yr��c c� City �p01 zlG lac# 7UL Phone# 1--(� <br /> Consultant/Sub CntrA/ Address "' City Lic# Phone# <br /> GIS Coordinates:X,3-11;9 '4`-iYL i Z1 Z-tb � Township 2-CJ Range Section Z <br /> WORK TO BE PERFORMED: � r� 1.' <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE-DIAMETER <br /> >B-WELL# a PRESSURE GROUT <br /> O'Other: Grout Specifications: <br /> COMMENTS: _9 -Care% d;Cv �V.�" 7�r//s 0o <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> itONITORING 0 HOLLOW STEM DIA.OF BOREHOLEj!�MULTIPLE CASINGS?Q'YES ONO WELL CASING DIA: t h. <br /> o EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING O STEEL e'M/C 0 OTHER: <br /> E VAPOR . WUD ROTARY DEPTH OF GROUT SEAL Z_ t TREMIE TYPE TO BE USED: 0 AUGERS ({HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 04es p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> E SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: Y cf /� _s v / q's <br /> a OTHER: 0 OTHER APPROX.BORING DEPTH 6 ut:� 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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. <br /> Signed x 5 �_. - Title/Company 0 CC'Z C e c ', c GS� -v P,V t� <br /> t <br /> Print Name Date1 {� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 0565 i�45Yec4hof 46P t-r-14112-0,SD <br /> WORK PLAN DATED: vo <br /> /� <br /> Application Accepted By_ _Date Issued Area"`�/ / <br /> Grout Inspection By Date S Zy OL Final Inspection By ate_ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED GH&WV RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ?fib 1 t9- Gb S �� (A '-w- 3 SRO O 63- <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> EI4D 29-02-001 WELL PEn4IT SFFE <br /> 8/27/2003 <br />