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aP <br /> WELL PERMIT APPLICATION FORWorwimEA i SITEAL711 <br /> SAN JOAQUIN COUNTY D x" T `WfflbATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT ( EC 5 <br /> "✓ 304 E Weber, Third Floor, Stockton, CA , 9� <br /> (209) 468-3449 <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 /> sessors <br /> WELL Location o Cross Street City SiOC CYOJ2_Z'p 5 rZ(� Parcel# <br /> AV-Arf0000 3 Glr.��` <br /> PROPERTY ,r7`b�L�s�—city aerR,hi� zip S Z6 Phone# 6 PSI- 3606 <br /> Owner w a,-JAddress q��d GO <br /> C-57 ContractorAddress_P QoY 6O_q City-O Zip` UfiLic da Phone#6"305' 9.2ZY0 <br /> .' // Address r o ityFacw�Lt Phone# �6 3-q 7l <br /> Consultant lSub Cntr Ve.N`Sa�+�"' �NG� 56cei''o <br /> 16 GIS Coordinates X <br /> y,,Township Range Section <br /> WORK TO BE PERFORMED DESTRUCTION (choose type below) <br /> KNEW WELL I BORING (CPT GEOPROBE HYDROPUNCH,HAND AUGER,OTHER`) OVER-BORE DIAMETER <br /> $SOIL BORING# 3 PRESSURE GROUT <br /> 0 WELL# GROUT SPECIFICATIONS <br /> 0.Other <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE 0 MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA <br /> V <br /> XTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING 0STEEL 0PVC 0OTHERAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED I]AUGERS p HOSE <br /> 0 AIR SPARGE!OZONE $PUSH POINT(GP or CPT)GROUT SEAL PUMPED 0 Yes 0 No (NOTE MAXIMUM*r' Ce rngrdt— WIN 6 REE-FALL DEPTH IS 30') <br /> )tSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS a <br /> 0 OTHER10 bell <br /> OTHER APPROX BORING DEPTH u 5 Fr_ 8 BOLTED TRAFFIC BOX or 1]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED AJQ (if YES list specifications in comment section) <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMIT <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordinances, Rules an a U tions, and all applicable California State Laws <br /> TktielCompany c C c6 <br /> Signed x <br /> Bate Z O <br /> Print Name +" DEPARTMENT" USE ONLY <br /> SITE MAP IN UNIT IV FILE,A DRESS' <br /> WORK PLAN DATED: Z' <br /> Date Issued �1+—Z2- Area db$ <br /> Application Accepted By Date <br /> Grout Inspection By Date_Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS <br /> A;OUNTING ONLY AID# FAC# <br /> PODES FEE INl 0 AMOUNT REMITTED ECHECK:#: REC'D BY DATEftPERMIT!SERVICE REQUEST# 71NvOICE <br /> S lao ty R# <br /> C-57 WG -WAIVER C-57 Letter of Authorization to sign permit <br /> ✓ Encroachment doc 9/30/02 <br />