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San Joaquin Countyyw <br /> Environmental Health Deartment I <br /> a ` p 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 FF D <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd '1/V101 <br /> ION <br /> q� FO N\P V/ROn'� •UV <br /> Well Permit Application /VT <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED RTES <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 5=Gjk o4� Cross Street P\ kln CityAssessors <br /> PROPERTY <br /> wcS�k Goan jc rv..n \' a o 'Q-U�^A <br /> r_ c �rrm—Zip Parcel# C. , tU j1 <br /> Owner �-r 5cA----Address_ 3y5 tJ E 1 Ooc- <br /> � Q"A_'City_ `�-ccL}�Zip fl�'to2Phone# <br /> C-57 Contractor S)" e'k' <br /> C-1., c h�� n ' i a ��Address mil 2 C-�Yra c cityIvo <br /> —� c'� -CAP, �c^-dou� Z�p�iLic# �5111'hone# `11b (o $- flbq <br /> Consultant/Sub CntrSe.C;;,r -c,,.,.�,,,,,Y��,.,��ddress�a �5 y�{yg <br /> City r-r�.o Llc#_t Phone# 'r gyp <br /> GIS Coordinates:X <br /> Y ,Townshi <br /> P Range Section <br /> WORK TO BE PERFORMED- <br /> Q NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") Q DESTRUCTION (choose type below) <br /> A-SOIL BORING# F, <br /> Q WELL# Q OVER-BORE. DIAMETER <br /> Q*Other Q PRESSURE GROUT <br /> COMMENTS:_ GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE <br /> Q EXTRACTION Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL Q OTHER: <br /> Q AIR SPARGFJ OZONE TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> )(SOIL BORING GROUT SPECIFICATIONS nc+..�b� „� <br /> Q HAND AUGER \ ho <br /> Q OTHER: n OTHER APPROX.BORING DEPTH L® ,�� <br /> Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED <br /> COMMENTS: (if YES,list specifications in comment section) <br /> p <br /> c <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 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 <br /> Tdle/Company <br /> Print Name <br /> '2.1 „ <br /> DEPARTMENT USE ONLY Date_ r�fLt <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z q b own I�n <br /> WORK PLAN DATED:_ , <br /> I <br /> Application Accepted B- <br /> Grout Inspection ey Date Issued 2 b Area <br /> Destruction Inspection By Date Date Final Inspection By Date Z Z O6 <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE EPERMIT/SERVICE REQUEST# INVOICE <br /> 350 ( .ov 6`(Z3o� 1-41 CC S6� <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to signermit <br /> EHD 29-02-001 P Encroachment doc <br /> 622/04 <br />