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an Joaquin County <br /> NlAY 1 "fironmental Health Department a SITE <br /> 304 , rAvenue,3rd Floor,Stockton,CA 95202 MITIrZATInk! <br /> EIvViR ax:(209)468-3433 Web:www.sjgov.org/ehd <br /> _ 6 PER 15 n <br /> ' Well Permit Application JU <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 applicalion <br /> Joaquin Countj Development Title, <br /> ,CChapter�(9.11115.3 and the Standards of San Joaquin County EnvIronmemal Health Dep <br /> WELL Location/_jC`1J ✓LK_ i� Cross <br /> Slree,./z/�*.7� <br /> PROPERTY/ <br /> Owner Zip mZip <br /> Kor <br /> C-57 Contractor/1C AddressY�G <br /> ^. <br /> City� C" Zlp��ic#_. <br /> ' <br /> Consultant ISub Gn[gC_fl:/�� Address.�3'23"��+'`/ 'Ttc�" �",E 5 <br /> Cil Lic# Phone# j <br /> GIS Coordinates:X ,Y— ,Township Range Section,_„ <br /> W21%19 BE CERFQRMAP: <br /> ' )IEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER*) Q DESTRUCTION (choose type below)" <br /> Q SOIL BORING A ggg QOVER-BORE. DIAMETER <br /> ARVELL If ® Q PRESSURE GROUT <br /> Q Other_ �� l GROUT SPECIFICATIONS_ <br /> t COMMENTS: <br /> i <br /> I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SFECIFFATIONS <br /> ' iONITORING OOLLOW STEM DIA.OF SOREHOLE4`Q MULTIPLE CASINGS Q MULL'I-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL--irVC Q OTHER: <br /> flVAPOR Q MUD ROTARY DEPTH OF GROUT SEAL ,�y'r TREMIE TYPE TO BE USED; ) AUGERS Q HOSE <br /> a AIR SPARGE/OZONE QPUSH POINT(GP orCPT)GROUTSEAL PUMPED: Q.Yes )(No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ' Q SOIL BORING Q RAND AUGER GROUT SPECIFICATIONS A/2­4� GG,� <br /> Q OTHER: Q OTHER APPROX.BORING DEPTH C2Rc �SOLTEO TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED __(if YES,list specifications in comment section) <br /> ' COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> ' 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br /> I hereby certify that B have prepared this application and that the work will be done In accordance with Sari Joaquin <br /> County Ordinances, Rules an gulations, and all applicable California State Laws. <br /> Signed x J.y// TitlelComparry__ C.y-FVY L1: <br /> Print Name„ .:! r�^ � G✓P!�.� Date ! _ <br /> vv DEPARTMENT UE O€� <br /> < � <br /> ' SITE MAP IN UNIT IV FILE,ADDRESS: F 'r <br /> WORK PLAN DATED: _ r <br /> Application Accepted By_- Gate Issued `F ®� Area <br /> ' Grout Inspection By_ Dale Final Inspection By - Date <br /> Destruction Inspection Sy Date <br /> ' COMMENTS I CONDITIONS: <br /> ^ <br /> I <br /> ACCOUPlTING ONLY: AtOk FAC# + <br /> ' PE CODES FEE INFO AMOUNT REMITTEDCHEC!:# R C'D 0Y DA7E PERMIT I SERVICE REQUEST# INVOICE <br /> m� SRIF " <br /> ' C-57 Vic -WATER_ C-57 I ettzr of 4ttharixetien to sign permitz Encroachment doc <br /> ERD 29-02-001 <br /> 6122104 <br />