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' San Joaquin County <br /> : Environmental Health Department <br /> i 304 East Weber Avenue,3rd lwtcT"2n, �� <br /> ' (209)468-3449 Fax: (209)468-3433 Web: Www.slgov.oehdh 1 <br /> r SAI 10a CU!H COUNTY <br /> EEAa•+� <br /> Well Permit Ap BtOMENTAL <br /> LT DEPARTN <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM OATS I D <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or Instal the work described. This application i <br /> Joaquin County Development Title,,/Chapter/a-1 115.3 and the Standards of San Joaquin County Envlmnmental Health Departs <br /> WELL Location !(riJ �i1p fGPp Cross Street City 4Zip <br /> PROPERT / <br /> Owner2iAddressL�YY>'/� f,` UtBy CItyZip6,f..+N Phana#G=fl �(,t7 <br /> C-97 Conlracter / /Addres�8 Dd7X 6 Clly)T�Zlp ��7�. d0 -honei♦ ��YCL.'�ilC) <br /> ' Consultant/Sub Cntr �Q t� / Addresa��Q��G��, - Ctly1,�LLlci1 Phone# <br /> GIS Coordinates:X .Y Township Range - Section <br /> ' WORK TO BE PERFORMED: <br /> tI NEW WELL j BORING (CAT,GEOPROBE,HYDROPUNCH,HANG-AUGER,OTHER') gDESTRUCTION (choose type Claw) <br /> Q SOIL BORING# r,�a OVER-BORE. DIAMETER Q <br /> D WELL PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: �� <br /> W• !; Tilictllo. � �2 g!5,6 .G rrwy <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING D HOLLOW STEM DIA.OF BOREHOLE_ D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D IiXTRACTION q AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: D STEEL 0 PVC D OTHER: <br /> ' D VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TORE USED, it AUGERS 0 HOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP orCPT)GROUT SEAL PUMPED: o Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS - <br /> 13 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or O STOVE PIPE <br /> ' CONDUCTOR CASING PROPOSED (If YES,list speciflasti In comment section) <br /> COMMENTS: <br /> ' NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. ll <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinancqg, Rules and Regulations,and all applicable California State Laws. <br /> Signed x TltiWcampenY <br /> Print Name —&/A&S Dale <br /> tDEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 100edr) D <br /> ' WORK PLAN DATED: <br /> Application Accepted By Date Issued 5-� Area 1 <br /> Grout Inspection By Date Final Inspection By Date <br /> ' Destruction Inspachan By Date <br /> COMMENTS I CONDITIONS: <br /> I <br /> ' ZG ONLY: EAID# FAC# <br /> FEE INFOT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 6 •os SR# 2- _ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc____ <br /> HHD 29-02.001 <br />