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�p4 .... SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT SITE <br />v <; <br />�'�I>,,� 600 East Main Street, Stockton CA 95202-3029 <br />�•. ,. rete MITIGATION <br />.4CJP/ phone: 209) 468-3449 Fax: (209) 468-3433 Web: www.siaov.org/ehd UNIT IV <br />WELL PERMIT APPLICATION <br />NON-REFUNDABLE 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 />�Il" ►, ��►1, a " city <br />(, zip <br />Assessors <br />Well <br />PLocatfot� owC1� 0f +tiGll I'L�K�.. Toss Street � �t- V��_ Ci 1,�QQ�i _ Zi Parcel # <br />OwnertlI4 Cf f Address U1 \A Prrr,.. St. City Dort( Zip �ZJ:LPhone* 2CPr•333.1[00b <br />C-57 Contract -�,,�� ,,���� ,�, . Address 3G 3 Z OlvNet Lr. Ci Lic # -A2po Phone 91(rG STS . 11 L4 <br />ConsultanVSub Cntr he AAS Address ��MM � City jp1SQIV1— Lic# Phon j4, ejZ. g <br />GIS Coordinates: X <br />Y <br />Township <br />WORK TO BE PERFORMED: <br />❑ NEW WELLIBORING (CPT. GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') <br />❑ SOIL BORING# <br />❑ WELL # <br />❑'OTHER <br />COMMENTSIAVA - IIII <br />TYPE OF WELL INSTALLATION TYPE <br />❑ MONITORING ❑ HOLLOW STEM <br />❑ EXTRACTION ❑ AIR HAMMER/DRIVEN <br />Range Section <br />ADIESTRUCTION (CHOOSE TYPE BELOW) <br />OVER -BORE DIAMETERa OD • �- S -1111 <br />��-Ii A <br />99tPRESSURE GROUT , .2 ._�_ 1 r _ (� 3 <br />GROUT SPECIFICATIONS <br />of <br />:TCML <br />CONSTRUCTION SPECIFICATIONS �:.1tfi �w�wc; tA�ii}t�S <br />DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />❑ VAPOR ❑ MUD ROTARY ._ _ DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE <br />❑ AIR SPARGE/OZONE D PUSH POINT (GP OR CPT) __-_ GROUT SEAL PUMPED: ❑ Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />❑ SOIL BORING ❑ HAND AUGER <br />❑ OTHER _ _ []OTHER._ <br />COMMENTS: <br />GROUT SPECIFICATIONS <br />APPROX. BORING DEPTH ❑ BOLTED TRAFFIC BOX OR D STOVE PIPE <br />CONDUCTOR CASING PROPOSED _ (if YES, 1st specx allona in Wo .M section) <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 � <br />e pr�epared this application and that the work will be done 1 accordance with San Joaquin County Ordinances, Rules and <br />Regulatlot all app11` J- Jali <br />Signed \04 <br />I Title/Compare `S <br />Print Name •_- l04Aj - Date 3 p <br />DEPA TMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: hjj�,/ D R <br />APPLICATION ACCEPTED BY DATE ISSUED � Q // Log AREA (' /- <br />GROUT INSPECTION BY _ FINAL INSP CTIO14 BY ` DATE O9 <br />DESTRUCTION INSPECTION BY DATE <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV D BY DATE <br />PERMIT/SERVICE # <br />INVOICE <br />U38'7g0 <br />r1 <br />SR#00S4Y9 <br />C-57 <br />E140290i 11r ui (WEB) <br />•• •• - �• ... �� r , �r� yr rev i r rvr�icrr i rvr� 1 v .�lul� �CRMI 1 <br />CNUM-)AI;FiMtN I UUQ <br />WELL PERMIT APP <br />