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u,�, 'San Joaquin County Cr2�LC� ,- <br /> r = Q Environmental.Health Department <br /> 304 East Weber Avenue; 3rd Floor, Stockton, CA 95202 OCT ( ATION <br /> i � V <br /> •=�� - • = - {209}468-3449 Fax: (209)468-3433 Web: wwwsjgov.org/ehd IV <br /> i�96R Well Permit Application PERr,it -,f;._ <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED J <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described.-This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-11115.13 and the Standards of San Joaquin County Environmental Health Department.Assessors <br /> ,3 <br /> ,,/� ,/ �t ! FGi_ � ro city p q�Z Parcel#-')r7 -17 3 -,o.z <br /> r WELL Location '47/"15 lY 1 6 rwil. Cross Street �� � Ci AcAwn Zi <br /> PROPS <br /> OwnerAddress l5 dolt! City r!. Wo Zi� ph.W 361-��ll� �J�.�� 1 C r <br /> C-57Coniractar Address Ci Zi L,c# hone#�e9T'17,1x`��YJ <br /> Consultant l Sub Cntr ( " Address 37 /city- ic#, 27 Phone#jzQf)w7`iC0(v <br /> GIS Coordinates:X Y Township. "L//V _Range 'Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL t BORING (CPT EOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTRUCTION (choose type below) <br /> SOIL BORING# I _ n OVER-BORE. DIAMETER <br /> !' Q WELL# -a PRESSURE GROUT <br /> D'Other ` GROUT SPECIFICATIONS. <br /> COMMENTS: — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS. a MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL p PVC U OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 150' TREMIE TYPE TO BE USED: 'XAUGERS a HOSE <br /> 0 MR SPARGE/OZONE PUSH POINT(GP oCPT GROUT SEAL PUMPED: 'Yes []NONO !(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING []HAND AUGER GROUT SPECIFICATIONS-_ i`c�TYr1x"A <br /> d OTHER:_G OTHER APPROX.BORING DEPTH ��?�_ BOLTED TRAFFIC SOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment sec'.ion) <br /> COMMENTS: <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 /> Cou rdinances, Rules and Regulations, and all applicable California State Lawss.' <br /> Signed x Title/Company 1 <br /> 6��i f7�cZ�ZJIrs <br /> Print Name/ Qc a G' Dater��O�!� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area { <br /> Grout Inspection By A I Final Inspecction By Date <br /> Destruction Inspection By t ate <br /> COMMENTS I CONDITION <br /> ACCOUNTING ONLY: AID# At- <br /> FAC# pILY4r` <br /> , <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# . R£C'D 8 DAT PERMIT/SERVICE REQUEST# INVOICE <br /> s o o SD ,8 a SR# 3 ] <br /> C-57— WCC WAIVER_ C-57 Letter of Auth iza o to sign ermit^Encroachment doc� <br /> EHD 29-02-001 <br /> 6!12104 <br /> ii <br />