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-3all oUayuiu %.-Uuilty <br /> Z� Environmental Health Department SITE <br /> 600 E. Main Street, Stockton,CA 95202-3029 MITIGATION <br /> (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/elid UNIT IV <br /> Well Permit Application <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 Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 11ti-Tor /I Assessors <br /> WELL Location "t 1yc,CJ � (� Cross StreA..A5 ity W=L+ Zip Parcel# <br /> PROPERTY�oH=��� <br /> Owner Address Z�V%k W%5 F-- City��-;, zip+4��;4cPhone# CAZ1 <br /> 31It2 <br /> C-57 Contractor­GAddressLArD Phone#4 b <br /> Consultant/Sub Cntr Address City Lic# Phone# <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> "EW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> PQtVELL#7-10 (=Iz,i P-lam P-t�5 s P-1�� 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: -rr-, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING fj�AOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS S--NCD TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL SC ` TREMIE TYPE TO BE USED: 0 AUGERS 'HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: '](Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS IyOiT C.- +\- 'Cl%zcw, <br /> 0 OTHER: p OTHER APPROX.BORING DEPTH S 8' WOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED i-lo (if YES,list specifications in comment se tion) �r <br /> COMMENTS: ' <br /> S <br /> 61-e W <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, Ru s and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company P /fin I-- -r r tiC� <br /> Print Name Date 1 Z r <br /> DEPARTMENT USE ONLY El f <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2-1 (t✓ i S+J\ 12" 4 <br /> WORK PLAN DATED: 12.1 11, 0i� <br /> FNViFUNNiENI ;IEA!TH <br /> Application Accepted By ` Date Issued n +" o4fdainrn <br /> T— --(�T?�tr}�TC <br /> Grout Inspection By LA .1 . Date 1 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> aOtcl � �591Cc I L-iG (, 121}(Cis SR# 56663 <br /> C-57-�/ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EI-ID 29-02-001web <br />