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SAN JOAQUIN COUNTY D <br /> ENVIRONMENTAL HEALTH DEPARTMEN ECi �Y <br /> 600 East Main Street, Stockton, CA 95202-3029 r � J� ,�VIITIGATION <br /> Telephone: (209)468-3449 Fax: (209)468-3433 Web:www.sigov.ol'g lfC1 3 201 UNIT IV <br /> ENVIRONMENT HEALTH <br /> WELL PERMIT APPLICATION PERMIT/SERVICES 6,6—r <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 /> �i a� ^ Assessor's <br /> Well Location�T °� aT. Cross Street p,!( City Zip 53 Parcel# 2,� <br /> Property �1 /� 11 <br /> r, / <br /> Owner 8 r Address aE; civ(_(_ (l.�Yi�Gv an.City Zip q!5 376 Phone#pb- 15.31-(Q�yM <br /> C-57 Contractor tl Address 5(7/fIT,�'n�C�4 �1 r' _City m►rf;in� Lic# 11D5 Phone q25'�'� <br /> Consultant/Sub CntrAmEC-(7ya,.0m.6riX Address.Z i f)l LAk65 et.C,4. 1d'^Ry} ity�Oaki�a Lic#&_14.�UPhone51) (0 _Vco <br /> GIS Coordinates:X !T7,�,. Y _ �✓- _ Township Range 5 &?SJ7 Section <br /> RK TO BE PERFORMED: <br /> ////����NEW ELL/BORING(CPT G OPROQE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br /> SOIL BORING# `�[ �p�.� (7,zy-f y(3� ❑OVER-BORE DIAMETER <br /> WELL# _ <br /> El PRESSURE GROUT <br /> ❑'OTHER ^ � GROUT SPECIFICATIONS <br /> COMMENTS: �Li1 Ja1^11LNUS L,V �aaS <br /> :y <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE'"3 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER �\ <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE yPUSH POINT(GP OR�_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> TVAI,C a <br /> SOIL BORING fAND AUGER GROUT SPECIFICATIONS rt 1a" t2•WI Q h� <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOS (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 certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,ar all applicable California Laws. <br /> Signed J� %�{p� Title/Company PtY'/y C ��C71Mlx <br /> Print Name t,le-i r(CII Date�� // <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BYDATESly D `V AREA <br /> .�. <br /> GROUT INSPECTION BY FINAL INSPECT «4 s DAT LX <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DAT PERMIT/SERVICE# INVOICE <br /> pZ /- !i0 SR# Q <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIG PER IT ENCROACHMENT DOC <br /> EHD 29-01 1115/07(WEB) WELL PERMIT APP <br />