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7: F ILS COPY <br /> WELL PERMIT APPLICATION FORIARvrL SITE-Al-1-ii <br /> SAN JOAQUIN COUNTY 3 ,T c <br /> - <br /> ENVIRONMENTAL HEALTH DEPARTMENT (E EC IS *TdY <br /> 304 E. Weber, Third Floor, Stockton, CA., 95 <br /> (209) 468-3449 I <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRONS DATE ISSUED <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 r-- -- <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> �, J Cross Street►Q� Ec1 Y—City Sr& i"'Drt_ Zip S Q Parcel# �i <br /> WELL Location 2QQQ—, r!^ c y� 1-4Q� <br /> PROPERTY City acra►+ir zip S 26 Phone#` L f?V 3646 <br /> OwnerL+Fy/lJw7: G u*Address12(2 <br /> C-57 Contractor fiE P,Pell to <br /> Address P CityQO Phone# 4S8 •2Z � <br /> Address r o ityfarw�Lic# Phone# 663'C A <br /> Consultant/SubCntr llP�►Sar . 54l <br /> 16 f GIS Coordinates:X <br /> Y ,Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION (choose type below) <br /> gNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER`) Q OVER-BORE. DIAMETER <br /> RSOIL BORING#_ r 1���1 �'�.` �'3 a PRESSURE GROUT <br /> n WELL# GROUT SPECIFICATIONS <br /> 0'Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> o MONITORING a HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> OF CASING: D STEEL o PVC n OTHER: <br /> TYPE <br /> EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS TF CASTREMIE TYPE TO BE USED: AUGERS Q HOSE <br /> []VAPOR a MUD ROTARY DEPTH OF GROUT SEAL <br /> n AIR SPARGE!OZONE ,$PUSH POINT(GP ar CPT)GROUT SEAL PUMPED: n Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH i5 30') <br /> $SOIL BORING HAND AUGER GROUT SPECIFICATIONS a*r" <br /> OTHER APPROX.BORING DEPTH �l 5 FY U BOLTED TRAFFIC BOX or p STOVE PIPE <br /> I]OTHER:----Cl if YES,list specifications in comment section) <br /> CONDUCTOR CASING PROPOSED__&Q-- <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPEC <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules an e u tions, and all applicable California State Laws. , <br /> Title/Company t .� t G k <br /> p' Signed x <br /> Date 2 Z Q <br /> Print Name �" DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,A DRESS: O <br /> WORK PLAN DATED: <br /> Date Issued <br /> Area <br /> Application Accepted By <br /> Grout Inspection By Date Final Inspection By ��� to <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC#,. <br /> -z REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> PECODES FEEINFO AMOUNT REMITTED CHECK# <br /> r � SR# <br /> ( 5 � 100 ly 5 <br /> C-57— WCC WAIVER.. C-57 Letter of Authorization to sign permit ✓ Encroachment doc� g/30/x2 <br />