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-o San Joaquin County <br /> A.- - <br /> Envl�nmental Health Department SITE <br /> "� 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 �CCCC„C���,�ATION <br /> 1'� (209)468-3449 Fax:468-3)449 468-3433 Web: www.sigov.org/ehd UNIT IV <br /> `R�C'_6 I'�EI�� 1 f, 211119 <br /> Well Permit Application _ <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENV{RO,IMFNT HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This rf�6�1�t�'r�u4��5� compliance with San <br /> Joaquin County Development Title,Cha ter 9-1115.3 and he Standards of San Joaquin County Environmental Health Department. <br /> xa�Clad �� Assessors <br /> WELL Location (J Cross Street city Zip�gParcel# <br /> PROPERT Pic, A`? ^�,i <br /> Owner Address C/J L ty Zipq_ �rhone# <br /> C-57 ContractorjnC[� C �iry �/i Address s2— 0,vyt�C Cts it -3�_Zip ,57/7'110Phone# 1063? /(C- <br /> Consultant/Sub Cntr f � Address e"5 1 J 2�e� 1CCity_ lic# Phone# �) 7 Y70L, <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL! BORING (CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER. OTHER") DESTRUCTION (choose type below) <br /> Q SOIL BORING# <br /> ER-BORE. DIAMETER <br /> — <br /> 0 WELL# ESSURE GROUT M ld • <br /> Q"Other GROUT SPECIFICATIONS b� MoV 1c <br /> COMMENTS: �y�s hA4_1 6 tq- / (U E l CiC <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING LLOW STEM DIA. OF BOREHOLE ULTIPLE CASINGS 9&LTI-LEVEL WELL CASING DIA: _ `A- <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 4-6 �`C�7�— <br /> TREMIETYPE TO BE USED: Q AUGERS Q HOS! <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 1),des Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30' <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS I V <br /> Q OTHER Q OTHER APPROX. BORING DEPTH BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> / CONDUCTOR CASING PROP USED (if YES, list specifications in comment sect!n <br /> COMMENTS: �1�E_ ✓�� VI.}. - i -�I.� �U�•Cj� (( �� ` — <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT 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 in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x W 9� Title/Company 14b E C-2(�-o/Fl <br /> Print Name �� 1 �`eP��-- ( Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By r // ` ! ! Date Issued G"i'� i� G/" �11..J Area <br /> Grout Inspection By ate 1 ? Final Inspection By <br /> Destruction Inspection Date <br /> COMMENTS/CONDITIONS: y ,� <br /> ACCOUNTING ONLY AID# :c_ C ', '(7cF a 2 f <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> fi+ <br /> SR# C- 2 � <br /> C-57___ WC_-WAIVER_ C-57 Letter of Authol�izat'ian to Sign permit Encroachment doc <br /> FHn zv_,r-uut <br /> 6/22/0.1 <br />