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_ Py <br /> WELL PERMIT APPLICATION FORM SITE <br /> 1v �p SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (END) UNIT IV <br /> ?i 304 E. Weber, Third Floor, Stockton, CA., 95202 <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 <br /> Environmentalt. <br /> Health <br /> ealth DepartmenAssessors <br /> ip � arcel# <br /> WELL Location rassSVeet, IC'tySy( >nZgti� 2 <br /> ERTYiq 5qq] CVCity C W Zip9P _ VjLq <br /> PRwOnePr Af AlamlCt Address $Z5 <br /> it14ZpRSd6 # W <br /> C-57 Contractor Ajuuoa PftVU Address 931 96aW C 6 <br /> Consultant!Sub ClCCAddress R37 n Phone#Q <br /> DDIo <br /> SWAJ <br /> GIS Coordinates:X <br /> Y ,Township Range Section <br /> WORK TO BE PERFO - <br /> 3ZNEW WELL/ PT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) O OVER-BORE.DESTRUCTION <br /> E UCTIAOMETER Dose type below) <br /> )(SOIL BORING# rL a PRESSURE GROUT <br /> g WELL# GROUT SPECIFICATIONS <br /> a-Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING a HOLLOW STEM DIA.OF BOREHOLEjar 0 MULTIPLE CASINGS p MULTI-LEVEL WELL CASING OIA: <br /> G EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: OSTEEL Q PVC OTHER: <br /> U VAPOR a MUD ROTARY DEPTH OF GROUT SEAL L'U l-f Pi TREMIE TYPE TO BE USED: I]AUGERS a HOSE <br /> 0 AIR SPARGE/OZONE WPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes $Tlo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING aHAND AUGER GROUT SPECIFICATIONS D -I' aAci <br /> GTHER: OTHER APPROX.BORING DEPTH _ �� a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED 0 (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 in accordance with San Joaquin <br /> County Ordinances, Rules andel Regulations, and all applicable California State Laws. <br /> Signed aWKf' L� N+rr"'" Title/Company G.eoIvii/J ^ 'ydKCQil GgO�V,fonvuOtKA <br /> Print Nameir Dale <br /> L tl �fiT <br /> DEPARTMENT USE ONLY <br /> y LB� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: SZl ✓• W <br /> WORK PLAN DATED: g• O Z <br /> Application Accepted By Date Issued Area Q <br /> Grout Inspection By Date Final Inspection By . r' to <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 PERMIi4t913JO102 <br /> 350 3d3I 2-11 SR#C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit ncroach <br />