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AI - <br />San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <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, Chapterp-11 5.3 and the Standards of San Joaquin County Environmental Health Department. <br />.l <br />Assessors rs <br />WELL Location Cross Street CitY /� Zip Parcel# <br />PROI <br />Owra <br />C-57 <br />I <br />Cons <br />City/ A— ' Phonae#/�c�/ <br />jres�/(3C) S� Cityl� Zip Lic#? 7-yPhone l6 <br />9ya p�y��J <br />Address- j .1 6 P t7 � CItyLic# r— Phone# Z-� ��� <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />p NEW WELL I BORING (CPT, OPR 8 HYDROPUNCH, HAND -AUGER, OTHER -)DESTRUCTION (choose type below) <br />SOIL BORINR # r� t� f ',�J V`VER-BORE. DIAMETER_ <br />3 WELL # �� <br />GROUT SPECIFICATIONS a PRESSURE O <br />� Other �� Q <br />COMMENTS: j" G 1 <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: ti <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: GAUGERS 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 0 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 />Signed x y TitlelCompany c (I er- <br />Print Name �S <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: Q <br />Application Accepted By Date Issued <br />li A <br />Grout Inspection By Date Final Inspection 8y <br />Destruction Inspection By Dale �- <br />vj <br />COMMENTS I CONDITIONS: _v_L, �� v <br />Arf'r%1 WTIAI!] nkil V• 1 AMR <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE REQUEST # <br />SR# s� <br />INVOICE <br />C-57 ✓ WC/ -WAIVER <br />EHD 29-02-00 1 <br />(n1mA <br />C-57 Letter of Authorization to sign permit_ ncroachment <br />