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l <br /> SAN JOAQUIN COUNTY <br /> . ,::. ,-ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> _- _ = , 00 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Teleph ne:(209)468-3449 Fax:(209)468-3433 Web:www.sioov.org/ehd <br /> UNIT IV <br /> WELL PERMIT APPLICATION <br /> NQIijREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> v. _ . <br /> Application is hereby made to SanJoaquinCounty 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 Environmental Health Department. <br /> Well LocationCross Street �� f �� I;� rrn ' c Assessor's _ <br /> Property -- City I > Zip f�, 4 Parcel# _46'I) : , <br /> Owner t <br /> iAress ` CiiY r y" zip C1 <br /> _�_- Phone �– <br /> C-57 Contractor Address City itv�� ` Lic# � Jhone <br /> Consultant/Sub Cntr E � f 't ice' t <br /> Address1h City _ E: Lic :� r: <br /> # ^�% Phoned 1- E Gc <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW ELL/BORING(CPTt:GE <br /> YTOPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# <br /> ©WELL# ❑OVER-BORE DIAMETER <br /> [}*OTHER 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> O MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ' f f4; <br /> ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION <br /> ❑AIR HAMMERlDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPORf <br /> ❑/MUD ROTARY. p DEPTH OF GROUT SEAL ( 4S TREMIE TYPE TO BE USED❑AUGERS[HOSE <br /> ❑AA/IR SPARGE/OZONE M PUSH POINT(GP OR CPT)G t GROUT SEAL PUMPED:[IYesQ No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> L��til!!(SOIL BORINGEl HAND AUGER GROUT SPECIFICATIONS <br /> C1 <br /> 0THER:TzS"9'"ref`P ttf r <br /> ❑OTHER:- APPROX.BORING DEPTH �(5 ❑BOLTED TRAFFIC BOX- OR ❑STOVE PIPE <br /> COMMENTS: (� C�j � ( ]��i CDN TOR CABgp <br /> IN PROPOSED <br /> 1 C^T �3 F { � 1if YEyS,list speciria�atig r ca��j�R67pfysect ort) <br /> +"�<s�1F11`"i�c''Y �i�4q <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that 1 have prepared this application and that the work will be done i accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all aWlIcable California Laws. ` ��{a <br /> Signed Title/Company I � � " -f 't"7i 5 <br /> Print Name 5� �'l Date <br /> J , <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: `�-� � ��!. L) _ <br /> WORK PLAN DATED: C 6L C E <br /> APPLICATION ACCEPTED BY DATE ISSUED « 24 d AREA g 7 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> � S R# DbZ_q?tP <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT— ENCROACHMENT DOC <br /> EHD 29A1 11/5/07(WEB) <br /> WELL PERMIT APP <br />