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San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd 2D ffPRck2n, ftj52pa <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.or ehd <br />v�;,!siE COUNTY <br />Well Permit Aj3o`ii(' IiUI IIENTAL <br />HEALTH DEPARTMENT <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <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 Y7090 A/` A404"Cross Street City Zip Parcel# <br />PROPERT Address�Y p3 Jy Phone# <br />Owner n Cit Zi <br />C-57 Contractor�����A,ddr.W L5 � Cityk- Zip /Lic#T�OO�hone#�"�—��Y�6�� <br />Consultant/ Sub (C,n6trl e t` �t -L� Address 2 ? City�5;- Phone# <br />GIS Coordinates: <br />WORK TO BE PERFORMED: <br />p NEW WELL 1 BORING <br />0 SOIL BORING # _ <br />0 WELL # <br />0.Other <br />COMME <br />Township <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />Range <br />Section <br />DESTRUCTION (choose type below) <br />le <br />OVER -BORE. DIAMETER d <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />g4 5. <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 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 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH D 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 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 />Title/Company <br />Signed x <br />- Date <br />Print Name ' <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: P66 <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By_ <br />Destruction Inspection B <br />COMMENTS 1 CONDITIONS: <br />II ACCOUNTING ONLY: I AID# <br />Date <br />FAC# <br />Inspection By <br />Area C <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE4 <br />P # INVOICE <br />.4�431 <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-001 <br />