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San Joaquin County <br /> cx Environmental Health Department y ` <br /> ` 4 <1 SITE <br /> 600 E. Main Street, Stockton, CA 95202-3029 ITIGATION <br /> (209) 468-3449 Fax; 209 468-3433 "_". =�` <br /> ( } Web: www.sjgov.org/ehd' <br /> Well r .,-;UNIT IV <br /> 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 9-111 V and the Standards of San Joaquin County Environmental Health Department <br /> WELL Location �`�.�;, ,y °Fw�y . <br /> Assessors <br /> t,102 Cross Street City �,fl CA-Zip � Parcel# <br /> PROPERTY <br /> Owner x, Address <br /> r� Zip one# <br /> -ic, t2"ZP-,h(7 oney#_— 7 <br /> 6CtlC-57Contractor AddressCity � lZf ,f <br /> _ j <br /> Consultant/Sub Cntriy? � Address k� s <br /> City �` Lic# L� Phone# <br /> GIS Coordinates:X ,Y ,Townshi <br /> p Range Section <br /> WORT{TO BE PERFORMED: <br /> ,Er15EW WELL/BORING (CPT GffO HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> D SOIL BORING# <br /> 0 WELL# a OVER-BORE. DIAMETER <br /> fl*Other 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE�`fI <br /> �_ Q q& TIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION a AiR HAMMER/DRIVEN CASING THICKNESS I TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: ------ <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL _�d`t: ITREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> D AIR SPARGE/OZONE;1410 SH POINT(&r CPT)GROUT SEAL PUMPED: D Yes D No•(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> �D"SOIL BORING D HAND AUGER GROUT SPECIFICATIONS /a <br /> [ OTHER: 0 OTHER APPROX.BORING DEPTH_y'_D 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> �. CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> „ J <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 anq Regulations, and all applicable California State Laws. <br /> Signed x � —E <br /> / Title/Company _ <br /> Print Name <br /> Date `� � <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: ,; - r <br /> WORK PLAN DATED: �- Jul, t7 <br /> N �J <br /> Application Accepted By LDate issued `] .2G Area� � <br /> Grout inspection By Y_. j ftd y MO- ��Date�-_�G WFinal inspection By V4 +e r,'a Mo .,f "Date__ — /G-b'7 <br /> Destruction Inspection By Date `�7 <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST* INVOICE <br /> 350 / 89.oa <br /> a 3 :2-8.5�a 37 '�, d pe5N �jy� ?�,zo a7 S R# 00513 7 <br /> C-57— WCC WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> EHD 29-02-041 web <br /> 6/22/04 <br />