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• �r� San Joaquin County COPY <br /> Environmental Health Department SITE <br /> La - c 304 East Weber Avenue, 3rd Floor Stockton, CA 95202 MIT <br /> (209) 468-3449 FaN (209) 468-3433 Web www S�gov org/chd TION <br /> UNIT I1/ <br /> \�` 0 Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Tcoma <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described This application is made inn/ce with San <br /> Joaquin County Development Title Chapter 9-1115 3 gnd the Standards off San Joaquin County Environmental Health Department <br /> WELL Location � , f';.,.�/ f},- „z / Cross Streecit �/�� I 2a; Assessors <br /> Y s Zip Parceltl //fid OLS <br /> PROPERTY s�ri�l P34-.,L,_ <br /> Owner Address_ .!f'/4 F A"— City_14 �Zip `I 2cS-Phone# <br /> C-ST Contractor &ec, Address qSC �Lr FCG� '1 City °lar ..fL�z�pyy�S�Lrc#`�a`5/LS Phone# `IZS-3l� S }o= <br /> Consultant/Sub Cntr Lars EK-fc„.~,4 L Address.[133 A/ 3 ce rQY.r_City Phi r- K Licff Phorre# Ee 2-7`�8- <br /> GIS Coordinates X Ni'} Y /1/.} Townshi TZ N <br /> A Range Section 3� <br /> WORK TO BE PERFORMED <br /> ,"EW WELL/BORING (CPT,GEOPROBE HYDROPUNCH HAND-AUGER OTHER`) Q DESTRUCTION <br /> D SOIL BORING# - (choose type below) <br /> $4NELL# Mw-13 DOVER-BORE DIAMETER <br /> a'Other �� '"� /�£ p PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS dk O 6 �r�f� f •• <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 11 HOLLOW STEM DIA OF BOREHOLE F Q MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA r' <br /> XTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_O I-V( TYPE OF CASING o STEEL APVC (I OTHER <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL f�r J),; rz iuSTREMIE TYPE TO BE USED gkAUGERS Q HOSE <br /> U AIR SPARGE/OZONE`OPUSH POINT(GP or(o�)GROUT SEAL PUMPED [I Yes 11 No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> D OTHER g OTHER APPROX BORING DEPTH i'5- (} bLT€D TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,Ilst specifications in comment section) <br /> COMMENTS t(t� Wr�� l�ia.el a_�.. s �.� �f 4,-e1p t C Agra-&- a,- - -il X " ? <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 Title/Company_�1fMlCflCD <br /> PnnI Name �1 a <br /> Date Z2 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FILE,ADDRESS. _ <br /> WORK PLAN DATED 2— 4 ,(a �V' <br /> Applica4on Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspectfon By Date <br /> Destruction Inspection By Date 4 <br /> COMMENTS I CONDITIONS <br /> COUNTING ONLY AID# FAC# ! <br /> E CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMITI SERVICE REQUEST INVOICE <br /> 50 4M 91 2 sR#po y <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permitEncr�ent daG�g� <br /> EHD 29-02-001 <br /> Lllr <br />