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SAN J OAQUIN COUNTY r ECOPYS - E <br /> -� ENN__JNMENTA,I HEALTH DEPARTMEi, MIT4 y <br /> 304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 IT I VAC_ <br /> (209)468-3449 •Fax:(209)468-3433- Web:www.co.san 'oaquin.ca.us/ehd �R f <br /> OP <br /> 60 <br /> WELL PERMIT APPLICATION FORM S N�gQUINC <br /> H RON CO <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DEPARTM <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 /> o <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department Om 1 w 1 8 <br /> Assessors <br /> WELL Location E F, t 0� rJ A vc, <br /> % Cross Street Vic. a 1AlcyNx City_SFc-c.'k,+&,. Zip ci z 5 - Parcel 0 <br /> PROPERTY Owner c 1, r�� 5-VL c> Sb%%Address "Z 5 c:c- circ<_v CityS k4" C' Zip C r Phon4 7,&2 <br /> C-57 Contractor lV4 R"a.Address'IVk_ S(,R-oC,/Xc city Zipr •Zt V U-c# Phone#j-(�( 2 Z S �,) -3 J <br /> Consultant/Sub Cntr Address City Lic# Phone# <br /> GIS Coordinates:X5 6 j Lt Y 1 -2-1 Z i> iy ,Township �. �' Range 1p_ tF_� Section , <br /> WORK TO BE PERFORMED: o""Gc tK e­L, <br /> -"EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose We below) <br /> 0 SOIL BORING# 0 OVER-BORE-DIAMETER <br /> f'WELL# 0 PRESSURE GROUT <br /> D*Other: Grout Specifications: <br /> COMMENTS: 2 � - c n. c b. v C W C [H-'s e a `y oy' n 4,,s <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 1) 72 MULTIPLE CASINGS?WS B NO WELL CASING DIA: .'-- cw� <br /> B EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESSSc-�, 6G1 TYPE OF CASING 0 STEEL D-PV'C 0 OTHER: <br /> 0 VAPOR . >B'fu1UD ROTARY DEPTH OF GROUT SEAL_j p t= TREMIE TYPE TO BE USED: 0 AUGERS eC£fOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: (Fres 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> B SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: _3 y ly<; • t, ) I� ,� <br /> B OTHER: n OTHER APPROX.BORING DEPTH G C.7 b B 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 /> �N b e n <br /> Signed x=1 Titte/Company S P C-S c 1 v 11 i <br /> Print Name �_ z,� Date 1;rl <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: "U56S ac .5d`a� GZj'e -/1/ Z9- Sa <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued <br /> Grout Inspection By Date 57-1(-O& Final Inspection By Date <br /> Destruction Inspection By Date m. -• - " <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED GLI.EG -fit REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 290 I 89 Mw S9 , Ob CRS N G 3 p(� sR* �l <br /> C-57 WC_-WAIVER_ C-57 Letter of Authorization to sign permit N Encroachment doc_ <br /> EHD 29-02-001 <br /> WELL PERMIT SITE <br /> 8!27/2003 <br />