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San Joaquin County"Environmental Health Department SITE <br /> East Weber Avenue,3rd Floor,Stockton, CA 95202 MITIGATION <br /> FA (209)458-3449 Fax;(209)468-3433 Web:www.sigov.org/ehd <br /> UNIT IV <br /> lit <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM 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 vvith San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> /� Calfe �} 9 Assessors f <br /> WELL Location C=- r" 1'�Ci_;" Cross Street N. rZ.L City I zip Payer# 1 D f <br /> PROPERTY <br /> Ovvnerpk (.atn^ Address o SA cityIuZip "�&lPhoe# <br /> C-57 Contractor 'tt[/i Address CityU-3 Zip9_ L&Lic# 1b1�p�none# 3 Y �f3o c, <br /> Consultant/Sub Cnlr_0,46 Address ` I. CW4'ity M4 Phone# 96 611 —ZZ 4 1 <br /> GIS Coordinates:X 'Y _ Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEWWELp SOIL/ BORA#G (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION (choose type bel <br /> v'ER-BORE. DIAMETER <br /> RING <br /> Q WELL# g PRESSURE GROUT <br /> GROUTS CIF[CATIONS <br /> COMMENTS: vtno-u ri t� ,,, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> bWONITORING a HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING .n STEEL a PVC BOTHER: <br /> 0 VAPOR' 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_ BOTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or 0 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 Ordinancgr,, R s and Resjulations,and all applicable California State Laws. <br /> Signed x r TitWCompany t <br /> Print Name \ Date p s <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, DRI=SS: <br /> WORK PLAN DATED: Z 2-00 <br /> r <br /> Application Accepted By Date Issued�1 , -�•+ Q—� Area / / 7 <br /> Grout Inspection By Dale Final Inspection By ` Date <br /> Destruction Inspection By Date 0 <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT SERVICE REQUEST# INVOICE r <br /> 3SdZ D°s �D°O Sia Cl? (c" 4 SR# ate "Z"3$ II4 <br /> C-57 W---WAIVER---WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc` f <br /> EHD 29-02-001 <br /> 6/22104 i <br />