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r <br /> POUIN ��� <br /> ,o r� SAN .10AQUIN COUNTY <br /> IQ a ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 FEB 0 6 * IGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:WWW.s o or /ehd �jNIT IV <br /> MENT LTH <br /> WELL PERMIT APPLICATION PERMIT/SERVICE <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 1115.3 and the Standards o Sa oaq/�IIn County Environ a tal Health Department. Asses <br /> 1y <br /> I V21 .1: tl tyg p -3z Parcel 1,1 <br /> Well Location . C ross Siree CON Ci Zi Parcel#� _/ <br /> Property <br /> Owner ✓ 0 1 va Addre�(ss Q r N City Ziip. Phone S �,y <br /> C-57 Contraeto y� 100'AddrLJs�gqNCity Clu Lted7#r/ � PhorfpJ�J�6��7sg7�('�Tl�Z7��J� <br /> Consultant/Sub Cntr Addresyc�� Ifk. City�Lic# y <br /> Phon <br /> GIS Coordinates:X Y .Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> El OIL BORIJG# E:1 OVER-BORE DIAMETER <br /> WELL# ❑PRESSURE GROUT <br /> OTHER . GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS n <br /> F1 MONITORING HOLLOW STEM DIA.OF BOREHOLE II ❑MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA: <br /> 11 <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS 1/4 b 1 TYPE OF CASING:❑STEEL /VC 1:3 OTHER <br /> [I VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USEDVI AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes [I Noj(NOTE:MAX MUM FRET <br /> -FALL DEPTH IS 30') <br /> ElSOIL BORING [IHAND AUGER GROUT SPECIFICATIONS fOy�/�ILj MAXIMUM <br /> CI <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH QJ ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> 1 J <br /> CONDUCT9R CASING PROPOSED (it ,lists cifimbonsincomnt section) <br /> COMMENTS: / <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR E CROACHMENT 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 I accordance with San Joaquin Count Ordinances,Rules and <br /> Regulations, applicab Ii NS <br /> jj / <br /> Signed Title/Company) � <br /> Print Name Date <br /> DEP1ARTM/ENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 135,20 C-1, ikiil.�,a. C( "A <br /> WORK PLAN DATED: �- <br /> APPLICATION ACCEPTED BY I;L . DATBISSUED o AREA 3b lc <br /> GROUT INSPECTION BY FINAL INSPECTION BY ' 's DATE Z6'' l <br /> DESTRUCTION INSPECTION BY DATE <br /> COM MENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> -Z40.l 29, CIO B , vo 1 1 3-5S111, SR# 5L 4ak <br /> C-57 4 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD2&01 1115/07(WEB) W 0'5�T0Z'M3+ERMIT APP <br /> rt4 <br /> l�10-.op <br /> ol t Aq <br />