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OPY+� p'pYMEN-'� "" 7 <br /> �a San Joaquin County 7AY VED <br /> y `� Environmental Health Department f1 SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 JUl 3 1 .... <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.ore/ehdJOAQUIN COUNTY UNIT IV <br /> ENVIRONMEAL <br /> L P R� Well Permit Application HEALrHDEPANTE <br /> H�LTH DEPARTMEr:,— <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 Develo Hent Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> � s <br /> WELL Locatio � C &UZip � Parcel# 1&V/70 C)—C/ <br /> PROPE e/--Zip ]� <br /> Owner /'/ Address .� / CityJ �hone#��7 <br /> C-57 Contractor rryt Address (L T�T7C L (fJ' /Cit -#A ZhTM/ o�� hone# <br /> Consultant/Sub Cntr �/ - CAddres" O�/0 —y'NCCCity Lic# Phone# <br /> GIS Coordinates:X ,Y ,Township Range_ZSection <br /> /_� <br /> WORK TO BE PERFORMED: /{syr/D /V / 6�( C9 / <br /> EW WELL/ BORING JCPT,G OPROBE,HYDRO UNCFJ HAND-AUGER,OTHER`) Q DESTRUCTION (choose type below) <br /> I SOIL <br /> )RING.# yt,�p a j' 15/'e_ 0 OVER-BORE. DIAMETER <br /> 11Y_-"0,.�_LL# L�8'rt /� a PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS t�r <br /> ,)I&0NITORING XOLLOW STEM DIA.OF BOREHOLEJ_lo R MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:4PR__ <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL XPVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS II HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yea a NNo�(NOTE: MAXIMUM FIR -FALI,DEh3TH Is 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS�IdYeT !A+/�rOnt���'�O_N � <br /> a OTHER: H p OTHER APPROX.BORING DEPT []BOLTED TRAFFIC BOX or STOVE PIPE <br /> CONDUCTO CASING PROPOSEDlist specifications in comment section) <br /> COMMENTS: 1� � P� � <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 Title/Companyite1� <br /> Print Name Date <br /> DEPARTMENT USE <br /> /ONLY z— / <br /> SITE MAP IN UNIT IV FILE, ADDRESS: v 6w-ST /V u� g V <br /> WORK PLAN DATED: IZ ' 2--05 ! v <br /> Application Accepted By Date Issued " 0 6 Area <br /> owV <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAG# <br /> PECODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �P) IFnOD ��90Ce 31 D SR# L <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to Sign permit_ Enc r,_c- me_nn/t doc_ <br /> EHD29-02-001 <br /> 622104 �tel? <br /> lC�� <br /> JC <br />