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San Joaquin County <br />Environmental Health Department_ SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 h F 'O_ ATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. ThisPdRA&W09;&E&ompliance with San <br />Joaquin County Development Title, Cha ter 9-1115.3 andAhe Standards of San Joaquin County Environmental Health Department. <br />��/}� ��� /� Assessors <br />WELL Location 06 ✓ I c � r Cross Street % �,�'�City Zip Parcel# <br />f)r\ 0-,\ i _:Y:/) <br />1• <br />hone# 7q 0302_ <br />Consultant/ Sub Cntr ' 1 (j 4'- Address P�) 1 � s l -"C_ city r Iic# Phoneo—k / 'Xi, <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING <br />0 SOIL BORING # _ <br />0 WELL # <br />0 "Other <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) /DESTRUCTION (choose type below) <br />G . ER -BORE. DIAMETER <br />ESSURE GROUT M W b 1 J <br />GROUT SPECIFICATIONS <br />4�1 <br />TYP_F= OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING 10LLOW STEM DIA. OF BOREHOLE�_" ULTIPLE CASINGS g4ULTI-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 46- h-ii�'-f_ TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: Ves 0 No NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS P° Q x X <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PR013p,�ED (if �YES, �list specifications in comment section) <br />( <br />COMMENTS: �{`� ✓�� /� Va — IA%-� [� `yu, 37 q a <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 (�C_ Title/Company A�-�� <br />67 0 <br />Print Name ✓i 1 t P�✓�-- �- t Date /) J' )'p 5 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: /, 1 <br />Application Accepted By \ I T <br />Grout Inspection By ate 1_1 <br />Destruction Inspection Date <br />COMMENTS/ CONDITIONS: <br />Date issued�� i,� Z �c`.'� Area <br />Final Inspection By Date <br />"L"-* C, 1, "1 <br />ACCOUNTING ONLY: AID# <br />C-57 WC -WAIVER C-57 Letter of AuthoKiz9416n'to sign permit Encroac oc <br />EHD 29-02-001 <br />6/22/04 <br />Zr'" = o C •SC ILO c v' cF 23 70( <br />'j <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D'BY <br />DATE <br />PERMIT REQUEST # <br />INVOICE <br />3 c7Z <br />�' L n <br />�: <br />.3ci <br />19 Cl S%' <br />Z I ��'i <br />R#00 C _17' <br />C-57 WC -WAIVER C-57 Letter of AuthoKiz9416n'to sign permit Encroac oc <br />EHD 29-02-001 <br />6/22/04 <br />