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San Joaquin County <br /> Environmental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)463-3449 Fax:(209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Lim <br /> 'FaR�'P 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 Tr�l <br /> Chap r 9-1115.3 and the Standards of San Joaquin County Envi on�w) <br /> ental Health Department. <br /> b� tKI `City p 6Asreel* sWELL Location # Cross Stree ZiParcel# ' <br /> PROP � p n�� // <br /> Owner s J LL Ad . T�'�f/:' � tt- kW CityW�, l� ZiPhone# t <br /> Contractor (l I (�J �6 Address+ F City ( r9 A Zipi,;!— <br /> C-57 �Lic#�Phone#� M �+ GJIC �> �. City N ubCntr 1V�� R! I Address Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERF IED, <br /> X.NEW W L BORIN CPT,GEO OBE, YDROPt�NCH HAND-A GER,OTHER`) a DESTRUCTION (choose type below) <br /> OIL BORING# - - -JC C P� ,/% ��/ �� 0 OVER-BORE. DIAMETER <br /> n WELL# -II ` c Yu /� / p PRESSURE GROUT <br /> a'Other J GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE't� 1 110 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:--_--- <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS ..,..TYPE OF CASING: a STEEL a PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SE At TREMIE TYPE TO BE USED: a AUGERS OSE <br /> p AIR SPARGE/OZONE r USH POINT(GP or CPT)GROUT SEAL PUMPED: O Yes o (NOTE: MAXIMUM FREE-FALL DEPTH 1 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS b/id-A(fiR J'�jfil <br /> a OTHER: a OTHER APPROX.BORING DEPTH 'u fBOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED L16 (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby �fy that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County rd j�a ce lutes and Regulations, and all pplicabte California State Laws. <br /> Signed x Title/Company t , rill' ( jao& l l <br /> Print Name_ Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ��eG ��4� L rr&An: P <br /> WORK PLAN DATED: <br /> �M <br /> Application Accepted By /° 1 - Date Issued a r' [ V � _Area <br /> Grout Inspection By -M' ^Date (( / C) __Final inspection By Date %L _ <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: /► S <br /> ACCOUNTING ONLY'. AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTEDCHECK# REC'D BY DATE i PERMIT t SERVICE REQUEST# INVOICE <br /> . . ----------- -------- <br /> C-57-1_-__ WC__-WAIVER_ C-57 Le"T, Ajj or,zat on to sign permit_ Encroachment doc, <br /> ! !n <br /> WEB Lf <br /> 3(j <br />