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OP'•�-= Y.,� 'lail Ouilqulll k_uulllJ ` TE SICOPY <br /> z z�, Envir--mental Health Departure . a <br /> IV <br /> 600 E. Main Street, Stockton,CA 95202-3029 MITIGATION <br /> tU ; <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sj-ov.org/ehI&Y 2 0 1' UNIT IV <br /> Well Permit Application PP 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 r,4_ 2'7, Cross Street city t-%"tel Zip Parcel# <br /> PROPERTY <br /> Owne -z? i Address'1-Z-\ \t_k ,, 5"C, City l-�T�I ZipG52�' ZPhone#l=Z � 33 -��� <br /> C-57 Contractors �w��.���}��r Address(. ~,f;`. ✓�3it���?Gity�-cr Lic# Phone# <br /> Consultant/Sub Cntr l= c 2S--, Address City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> -jrVNELL# -Q i NT&_-"x✓' 0 PRESSURE GROUT <br /> 0*Other n GROUT SPECIFICATIONS <br /> COMMENTS: 'mss �� P' sf- P --- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �l <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 ' TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 'Z L`i 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 /> 'OTHER: 0 OTHER APPROX.BORING DEPTH -4-7�� BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> Fd��_rY1*�y e�`� 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 Ordinances, R an Regulations, and all applicable California State Laws. <br /> Signed x Title/Company !-'4 <br /> Print Name ~ _Date_S <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_ �2"� <br /> WORK PLAN DATED: '/ <br /> Application Accepted By 7 06kL-t y \ Date Issued �'2�"rQ ETK /&� <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE gCODESjjFEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2� - /7 2 1 I 1!ow,rc-Q S2�(-12 SR#C- WCC WAIVERS_ C-57 Letter of Authorization to sign permit-! Encroachment doc t1 iR <br /> EHD 29-02-00 1 web <br />