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R� <br />San Joaquin County <br />Environmental Health DepartmentCouSv SITE <br />600 East Main Street, Stockton, CA 95202-3029 SAN JOAQutNENT <br />ENVtRpEPARTMTIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.org/e�p,-T" UNIT IV <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 with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />I Assessors <br />WELL Location 3Z+t i S 1✓ (` k Cross Street 1 V "� City jt 'Vl Zip Cf UiParcel# 0_"yb 2t)ZA <br />PROPERTY n <br />Owrpr U `11 t t <br />rIF �� <br />�^ i2�Phwe# 1(} � of r <br />\1 t't�G i�rs lit a .`t:i0 f� CPS- <br />C-57 Contractor Address City Zip Lic# Phone# <br />�t 12.`I <br />Consultant I Sub Cntr M, ki' Q A UVG � MJ Address S u s 4e. -2W City tIc^r Lic#��I�3�a C Phone# <br />�0 I s o C, t to 3 <br />GIS Coordinates: X ~ 1� V `� Z �4 a , Y 35 U A!'—, Township 1�j Range Section <br />_WORK TO BE PERFORMED: <br />EW WELL 1 BORING <br />Q SOIL BORING # _ <br />D WELL # <br />COMMENTS: <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") <br />S vt7� <br />p DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECI"^ATtnMS <br />A ' <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING fiOLLOW STEM DIA. OF BOREHOLE p MULTIPLE CASINGS U MULTI-LEVEL WELL CASING <br />0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: U STEEL 0 PVC OTHER: <br />0 VAPOR Il MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />0 AIR SPARGE/ OZONE p PUSH POINT (GP or CPT)GROUT SEAL PUMPED: p Yes a No (NOTE: MAXIM}U,M �F�R�EE-FALL DEPTH IS 30') <br />D SOIL BORING G HAND AUGER GROUT SPECIFICATIONS trt'' b'A �x yyt fit�l - to <br />hVHER: Q OTHER APPROX. BORING DEPTH 1316-- BOLTED TRAFFIC BOX or STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS:' , (e \i e_r%�}jo. ks <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 Ordinances; RAIAes and Regulations, and all applicable California State Laws. <br />Signed <br />Print N <br />Title/Company <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED:.._____._ <br />Application Accepted By /v4/ �^`��� �A Date Issued ��% 2 �� Area <br />Grout Inspection By '_r Date 41,17'V09 Final Inspection By ,v r Bate <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT/ SERVICE REQUEST# <br />INVOICE <br />C-57_ WC L WAIVER_ <br />EHD 29-02-001 WEB <br />9/11/200; <br />C-57 letter of Authorization to sign permit_ Encroachment doc_ <br />