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SAN .JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> +¢ ,. <br /> "7-LOO East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Teiepi one:(209)468-3449 Fax: (209)468-3433 Web:www.sigov.ora/ehd UNIT IV <br /> .� <br /> till ,, '(1 ,1008 WELL PERMIT APPLICATION <br /> TML <br /> F LFUNDABLE 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 /> e L� Assessor' <br /> Well Location Cross Street City Zip� Pacel#Properr r <br /> Owner 1�� g �I^Fi�L / I 7 �! <br /> Owner f I t f Address N. <br /> 2Q 1�_ City �1 f 5 Zip 1�,JPhone# <br /> C-57 Contractor Address 22'O I". 60t 1, S ly u - City 1 �v�1c1� Lic# phone 24 2t1 <br /> Consultant/Sub Cntr Address lad r'r1aL ICA7 City ©ci Lh-A Lic# N/!k Phone Sf0-46('-7A4? <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROBE,)ti`DOPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑ 'OTHER GROUT SPECIFICATIONS <br /> COMMENTS. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE J�❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:N/ <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS �/ TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER NA <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEA r / <br /> (� q��f�TREMIE TYPE TO BE USED❑AUGERS HOSE <br /> El AIR SPARGE/OZONE PUSH POINT(GP OR CPT)Gt GROUT SEAL PUMPED:[I Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> & OIL BORING �r [I HAND AUGER GROUT SPECIFICATIONS Neafi Ce,�,� <br /> OTHER:T�"Y' °1�Y "Ct ❑OTHER: APPROX.BORING DEPTH "t�/ ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONp�JC�TOR CASING gROPOSED (if YES,list specificati in m ent section), <br /> COMMENTS: A G°r t PrC=( I SC+4i�1 JN/1(l�7P %�IS�I hYlc�/ Ib (O PC ci✓tx?�► I /i ll/1�M/� C'S .7', Wi <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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all aplicable California Laws. c <br /> Signed / / Title/Company Fro t°C� �0��21 Sf // <br /> Print Name ���� y-(?k Date ►1�Iy/c <br /> pDEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: C rQ,, C, <br /> APPLICATION ACCEPTED/BY �/��� DATE ISSUED f( D e AREA q <br /> GROUT INSPECTION BY /`dt FINAL INSPECTION BY DATE�f ``i <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: &� <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 0C QI,7 SR# 0 o r0g7te <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PER IT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />