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QLr,��`�'"'i <br /> � J iJ <br /> • -i'� SAN JOAQUIN COUNTY `=� I Ln <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029N <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.s' ov.or IV <br /> WELL PERMIT APPLICATION ��1 14 20�$ <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED M <br /> owumApplication is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicatio �i#q�l ekCVhl�San <br /> Joaquin County Develo rent Title,chapter 9-1 15.3 and th Standards of San Joaquin County Environmental Health Depa <br /> �ule Ave. w-f � w��Sw�1i flue. Assessor's/1_ ROw <br /> Well Location f4•��^�f'f i <br /> LA* <br /> 5•+i ,C �Str et w;10v' Wa- (L°y'^ ��ity S�°c � Zip Parcel# (.® <br /> Pro a �. •� v... (sr C.6.-4wlG <br /> owner c,wwbyt� Address 14510 E• ttgtzel}w. Ave_ City S�ocl< Zip `T�zQI Phone# ��fl' 3Quo <br /> cT� <br /> C-57 Contractor �Ye ",�l,i'.{IN ddress 95'0 Howe a. City�na,�}i• e z Li hone 92t'- <br /> lriavoa' ze' Sfi y �scalay. uo# Phone $?£f 9i<kf� <br /> Consultant/Sub Cntr Ar-Akyj ,.S/ Address 1 14 mo%'^ c+' Cit <br /> GIS Coordinates:X TMU-1. Y—12-1•2,11 Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") [3 DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# y�e HPL ❑OVER-BORE DIAMETER <br /> WELL# ❑ PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING [3 HOLLOW STEM DIA.OF BOREHOLE Zn ❑MULTIPLE CASINGS[IMULTI-LEVELWELL CASING DIA:N ' <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS Iv P% TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR 1�❑ �MUD ROTARY DEPTH OF GROUT SEAL 60 ? - TREMIE TYPE TO BE USED❑AUGERS HOSE <br /> IR SPARGE/OZONE T3]PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:�Yes a No (NOTE: `MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 61 HAND AUGER GROUT SPECIFICATIONS N"A- f e��T lrf o'Or <br /> OTHER: [3OTHER: APPROX.BORING DEPTH lD o FE ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCT CASING PROPOSED (i YES,list specifications in comment section) <br /> COMMENTS: 13orir�S Cow. oIe{C'c� wilt. av, o.t0lrIR P arc <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 1 accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,andallapplicable Califo la Laws. <br /> \�+ rr _ <br /> Signed 1-- Title/Company y I <br /> Print Name 6 i e Z— Date I R 0 <br /> DEPARTMENT USE ON/L�Y� 35.03��� �y <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z <br /> WORK PLAN DATED: 8 <br /> APPLICATION ACCEPTED BYDATE I E !D' g AREA �rG4 <br /> GROUT INSPECTION BY FINAL INSPE ~� I S1' /� <br /> f DATE '7i!'� <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CON DI TI ONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> C-57 WC V -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENTDOC <br /> EHD 29-01 11 1/5A7(WEB) ""��/)�►0����APP <br />