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,o San Joaquin County <br /> r Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 952 <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd u l%�L IGATION <br /> NIT IV <br /> Well Permit Application pOCT 2 6 20 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS Rp,L0WNItifEIVT H rVAssessom <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work describ d. T4Rs� <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San J aqui r{��C,ounty E onmental Heif h pAh' <br /> WELL Location�I,J.� �h" "' � A Gross Street a�f�/1City ZiP J9 3 �.� <br /> PROPERTY � <br /> Owner (/d Address �' 77 -'''� <br /> C-57 Contractor W V G City�ZIPL�Pho aj�x'00 <br /> J Address Q city L Zips! 5k hone# <br /> Consultant/Sub Cntr afpt7l:/`f�f6�Or Address-2f2 r,/`7Ji/-! City i��t Lic# Phone# <br /> GIS Coordinates:X ,Y ,Township Range 9 Section <br /> WORK TO BE PERFORMED, <br /> TYNEW WELL/ BORING GEOPROBE HY OPUNCH,HAND-AUGER,OTHER`) ]]DESTRUCTION (choose type below) <br /> C" 0 SOIL BORING# �-� /� <br /> DWELL# DOVER-BORE. DIAMETER <br /> a*Other ]]PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ]]MONITORING ]]HOLLOW STEM DIA.OF BOREHOLE— 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING <br /> ]]EXTRACTION ]]AIR HAMMER/DRIVEN CASING THICKNESS_TYPE OF CASING: 0 STEELC <br /> 0 VAPOR ]]OTHER: <br /> 0 MUD ROTARY DEPTH OF GROUT SEAL_TREMIE TYPE TO BE UED .kA UGERS ]]HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ]]Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING O HAND AUGER GROUT SPECIFICATIONS Aoat S-=e <br /> 3KOTHER: _a OTHER APPROX.BORING DEPTH � <br /> ]]BOLTED TRAFFIC BOX or 'ST <br /> COMMENTS: OVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <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/Company O <br />/ Print Name <br /> k <br /> " 4C 0) � ! DEPARTMENT USE ONLY Date <br /> SITE MAP IN UNIT IV FILE,ADDRESS: LS'a <br /> WORK PLAN DATED: <br /> I <br /> Applicaton Accepted�B <br /> Grout Inspection BX_� 6dC_( Date Issued /U <br /> Area9 <br /> —Date <br /> ( pL <br /> 7 <br /> F Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> o 8? PZ >5 v -7 sR# 'o <br /> C-57_ WC_WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />