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U1 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East MainStreet, Stockton, CA 95202-3029 MITIGATION <br /> -3454 Fax:(209)468-3433 Web: .0ra,!29AII UNIT IV <br /> Telephone:(209)468 WWW.Sia0v <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hil,�bmade 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 Developme9t Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessor's. <br /> I-e j-0 <br /> Well LocatiodP:--� Street e"jCity, e-co r - Zip Pircel# <br /> Cross S 0-6 <br /> Prover <br /> ro - .3 <br /> Pe City <br /> ner1AW17U;*4x4/^_/ 0/ Address le?D C 9 S'�CoPhone# A9 C,14F <br /> City (ef S-Z- c# IprlKd�p <br /> C-57 Contractor hone <br /> Leic?V � Phone <br /> Consultant/Sub CntrllC(��CIP__6_:_r-,t/'fAddre,, C— <br /> Vi�l <br /> GIs Coordinates:X—,?e CA- Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> [I NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(CHOOSE TYPE BELOW) <br /> []SOIL BORING# -"E]OVER-BORE DIAMETER <br /> El WELL# 9PRESSURE GROUT <br /> El*OTHER GROUT SPECIFICATIONS <br /> El EXPLOSIVES DETONATING CARD <br /> COMMENTS: ep� 11r 'e'v e_02 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 10 MONITORING HOLLOW STEM DIA.OF BOREHOLE /0 MULTIPLE CASINGS[I MULTI-LEVEL WELL CASING DIA.. <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS z521"t 4K_0 TYPE OF CASING:0 STEEL 1750VC F-1 OTHER <br /> 0 VAPOR El MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED[I AUGERS[I HOSE ZN <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:[]Yes 0 No (NOTE:MAXIMUM FREE-F,,'+L DEPTH IS 30') <br /> 0 SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS <br /> El OTHER: 0 OTHER: APPROX.BORING DEPTH - 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,fist 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 prepay I application and that the work will be done I accordance with San Joa uin o my Ordinances,Rules and <br /> Regulations,and all applicabl fo isLaws. <br /> 7' <br /> Signed Title/Company <br /> I <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> z <br /> GROUT INSPECTION By FINAL INSPECTION BY 191-el-I ATE e11111-L' <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: z <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECVD BY DATE PERMIT/SERVICE# INVOICE <br /> 4-f If 7 2— 0000 ' ')P SR#004,671 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2MI 10/28109 WELL PERMIT APP <br />