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SAN JOAQUIN COUNTY <br /> r'a ENVIRONMENTAL HEALTH DEPARTMEN�f'CEI E SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> _ Telephone:(209)468-3449 Fax:(209)468-3433 Web:WWW.si r / hdd?009 UNIT IV <br /> 1;•. riya c± <br /> WELL PERMIT APPLICATION SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE WWWDEPARTMENT <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 <br /> /De/vtellopm�e�nt Title,`chapter 9-11115.3 and the Standards off San <br /> ^Joaquin County Environmental Health Department. <br /> (0'f p� N• �lrtF[I/ IQL�Cross Street <br /> /C.(J/Tu City <br /> p Assessor's <br /> Well Location ! /� � �//����LL ,f C L Zi Parcel#Pro ,/ <br /> Ownerty50 40ydio 000V y Address GL-C.'-C v 4:, Zh!U ZOA)�Cty Zip Phone# 6 ,-9S �i2 <br /> C-57 Contractor k. , 2d,&A47/`N Address.3ff 3 C AVIC l U Pf& City i4eJCkZW Lic# kJ Phone j/g 733Y��zU® <br /> Consultant/Sub Cntr Address City Lic# Phone <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> a-OTHER WaAw g GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING N HOLLOW STEM DIA,OF BOREHOLE !MIA1 W MULTIPLE CASINGS INMULTI-LEVELWELL CASING DIA <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS i© /S TYPE OF CASING:❑STEEL ❑PVC &OTHER We <br /> 6APOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> R SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> [3 OTHER: ❑OTHER: APPROX.BORING DEPTH V D U5 E3 BOLTED TRAFFIC BOX OR [3 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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,and al plicable California Laws <br /> Signed Title/Company 654a`r, LF9 6 <br /> Print Name Af Date —�--- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUEIP AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> t <br /> OUNTING ONLY: AID# FAC# <br /> ODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> $�j 1�`/� L .�i) SR# <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT' ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />