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�a San Joaquin County no `�a <br /> ����'Env' omental Health De L� <br /> I-Iopov <br /> � partment•,r E <br /> { 304 East Weber Avenue, 3rd Floor, Stockton CA 95202 MA'Jla TION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> �`P ENVIRUNNIE N � <br /> Well Permit Application PERMIUS J <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 e to ards of Sa Joaquin County Environmental Health Department. <br /> WELL Locatio ros� ZAssessors/ _ <br /> � Cross Street ����Cit Zi Parcel# ?� � -O <br /> PROP Y /��.�,^ /I — <br /> Ownertfl� �-�I�Address_2L U/11�j - L� //// <br /> �f Ci - 110a�Phone# <br /> C-57 Contracto�c'asna T�Vi( "vL Address <br /> �,/`� /�— City �iPj��ic# <br /> Consultant/Sub Cntr Address 53-? 'S , P'kPhone# 2o6T 4� I c 1 <br /> CitjcLic# <br /> GIS Coordinates:X Y Township Range 9 Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER') 0 DESTRUCTION <br /> 0 SOIL BORING# (choose type below) <br /> 0 WELL# o OVER-BORE. DIAMETER <br /> 0"Other 0 PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �'h�IONITORING "HOLLOW STEM DIA. OF BOREHOLE ULTIPLE CASINGS0 MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS A114- TYPE EO��OF�CASING: 0 STEEL 0 PVC 0 OTHER: __ <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL�3Q O¢9p !` EMIE TYPE TO BE USED: k1<UGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 2No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS �Ov�L4`t1Gf <br /> 0 OTHER'_0 OTHER APPROX. BORING DEPTH &d 6.60LTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> �l/[Hyl I�N'1Q IIJ�lel S <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 and Regulations, and all applicable California State Laws. <br /> Signed x_ <br /> _1 Title/Company <br /> Print Name 1� 1 L �7 Date `3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: a�T�' 'A —'�;a <br /> WORK PLAN DATED: 2� -Tan 2 <br /> Application Accepted By Date Issued y Area LI <br /> Grout Inspection By (A�1 Date �!, �o Final Inspection By clL L C, Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# ' <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3W-o -00 <br /> 3 03 z-+-q.009f (� 4SI`/ID5 SR# O0�-(33 -7'01 <br /> C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit v' Encroachment doc <br /> EHD 29-02-001 <br /> (10M a <br />