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ORIGINAL <br /> JU"llliUlll <.VU11L,' ` ' <br /> .�f nRECEI V SITE <br /> 4 7� z Environmental Health Departure <br /> 600 E. Main Street, Stockton, CA 95202-3029 MITIGATION <br /> i y ' (209)468-3449 Fax: (209)468-3433 Web:www.sjaov.org/eimAY 2 4 2012 UNIT IV <br /> Well Permit Application ENVIRONMENTAL HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEBERMIT/SERVICES <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 /> Assessors <br /> WELL Location 7�X W,-ToiZ►s=tZ Q 7. Cross Street City 'r-P1 Zip `R ;?_4Z Parcel# <br /> PROPERTY <br /> Ownervd't-10;= Address'L-Z\ �„i�,��sy; 5-C. City l-�T;1 Zip�+5Z4Zphone#t2�R�333 -�a-� <br /> C-57 Contractor�G ,�� iaS t�.K Address(aft �l_O�kt? �.GityG Phone# Ctrl. 3�i3 <br /> Consultant/Sub Cntr 41 ., Address CityLic# Phone# <br /> GIS Coordinates:X 'y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> /ELL# p► kAoS r✓Ll1 f>1 iP) 2 a PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: 'fit 7� ;��y -� 1 - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE'0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: \ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS.S— TYPE OF CASING: 0 STEEL )(PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL `Z t"i t TREMIE TYPE TO BE USED: GAUGERS `HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 'AOTHER: 0 OTHER APPROX.BORING DEPTH 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 ha a prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, R an Regulations,and all applicable California State Laws. <br /> Signed x Titie/CompanSAy9E-"9_77� <br /> Print Name h Date S !'Z��1 2 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_202 <br /> WORK PLAN DATED: 2� ?Q 12 - <br /> Application Accepted By O bate Issued — ea G <br /> Grout Inspection ByZ46&ip�15ate 6 Z Final Inspection By Date Q 2__ <br /> Destruction Inspection By4F 1 D e L <br /> COMMENTS I CONDITIONS: v <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �0( 1'7 2-1 cowum--k 5'.4-f2 SR# <br /> C-5 WC r/-WAIVER C-57 Letter of Authorization to sign permit c/ Encroachment dock <br /> EHD 29-02-001web <br />