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San Joaquin County nnD 11 V�1L <br />Environmental Health DepartmlC ENEY-R-S' <br />ITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95' I I MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org%ehS ?00�' UNIT IV <br />Well Permit Application ENWHONIMENT HEALTH <br />PP PERMIIT/SERVICES a �^ �.�� <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED /Y <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 />QQ / j ,� Assessors /; p <br />WELL Location �� lQy �'*�`�" r Clon Street city _I�I/�I VI ym Zip Parcel# "t <br />OwnerPROP/d� 5l AddresVV CitZ' 7OJphone#(i01" 7JU <br />C-57 Contractor <br />Consultant / Su <br />GIS Coordinate: <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />IL BORING # 0 OVER -BORE. DIAMETER <br />LL # a PRESSURE GROUT * `� <br />0 "Other GROUT SPECIFICATIONS 1 v <br />COMMENTS: <br />PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:__ <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSL TYPE OF CASING: 0 STEEL VC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br />0 AIR SPARGE/OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: %ZA1 <br />o (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONSI ��i "rjl %�I� , (�E L1�'�V11 f✓1y�1-t I- '�� IidA: <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH ? 1 hGis BOLTED TRAFFIC BOX or 0 STOVE PIP <br />COM <br />DUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />W J- 21' 0(AS- <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, Rules and Regulations, and all applicable California State Laws. <br />Signed '��I�%/�(�� Title/Company � i1oc� <br />Print N <br />V <br />SITE MAP IN UNIT IV FILE, ADD <br />WORK PLAN DATED: <br />Application Accepted By. <br />Grout Inspection By <br />Destruction Insoecti <br />COMMENTS / CONDI <br />DEPARTMENT USE ONLY <br />16,.S00 .s. <br />-/3-6 <br />Date <br />Date <br />inal Inspection By <br />Area <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />R�EC'DD BBY- <br />DATE <br />P SERVICE <br />VOICE <br />SR# f� D <br />C-57 ✓ WC ✓WAIVER_ C-57 Letter of Authorization to sign permit_Encr ment doc_ <br />EHD 29-02-001 ('�-vJd- <br />6/22/04 <br />