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1 <br /> San Joaquin County <br /> Environmental Health Department Fig S -1 <br /> 8 <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 10WOOS <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd � <br /> - °9L,�o���P • Well Permit Application <br /> S <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 /> WELL Location L`l R Wim' Cross Street City ' Zip Assesso(sParcel# 0`0 •-10�O ' 37- <br /> PROPERTY 7- <br /> PROPERTY pc �GY Yr�4`1 <br /> Owner P.Vkcac\kr-;L- 1-:C�S ix-yAddress City M Cy'a as Zip 5-16Phone#_C'1tS)1-1`1 'S3C{`1 1 <br /> frac p�:�lLr. ty`� P� -1-i ic#,t,V�Phone#Otbl�03F(-ll <br /> C-57 Contractor C�a� �- �ddress''S�o 3•L e;rne.C. Ci Zi b5 <br /> ,Sour 5'.rc'car c^nc�\ �i�`lSC <br /> Consultant I Sub Cntr Address 3o 1-1 C.\g�0. City x-010 Lic#_�-11='_Phone# (_"iIk. ki,4 <br /> G Gin <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> -gNEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER") Q DESTRUCTION (choose type below) <br /> jr,SOIL BORING# 3 Q OVER-BORE. DIAMETER <br /> Q WELL# Q PRESSURE GROUT <br /> Q*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE!OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> 'SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS ;t" <br /> Q OTHER: Q OTHER Sin tic-. APPROX.BORING DEPTH knio Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: SIZA k As-to <br /> 6t- � t-1:-- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT O'R ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 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 !Ng'—h� �l� Title/CompanyR� SC.�in�i5ck � s�-tar Ttit{a.cY�oeltcSr�e� <br /> Print Name �c��'wao. (t�v�X Date 1 t <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,A DRESS: Aq (, I�e 176 L4 ' <br /> WORK PLAN DATED: 5 '2- D Y <br /> Application Accepted By Date Issued(�/O� Area _ <br /> Grout Inspection By a �i Date 2. Z O Final Inspection By Date -4 Z G{7 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 32t SR# <br /> C-57� WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc— <br /> EHD 29.02-001 <br /> 6/22/04 <br />