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i • FqWo 6 q f; <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION <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 Stand rds of San Joaquin County Environmental Health Department. <br /> �G,yf!/?/✓6 t D/IP//�Oi✓D L O�/ 9$ Parcel <br /> Well <br /> Assessor's <br /> Well Location I'V 7 .5 <br /> Cross Street City Zip c� Parcel <br /> Prope er�s�i✓c/Oi9QG ""tl--Y'Address /fl''9 C hW 2 C'G 70^lCih, S7747Z4%O/✓Zip/S�OI Phone <br /> Pwo- ey-Iv <br /> C-57 Contractor Address City Lic# Phone tc <br /> COnsultant/Srtis6fitr SC S' /X l LDAddr�sR 70 `+i ��PR �PR G'�ity ���� Lic# Phone��9 S�� T S 0' <br /> GIS Coordinates:X de Y de 0/" ,Township e2 N0l?/H' Range Section-;)17 <br /> W RK TO BE PERFORMED: <br /> = VVELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ////!! ❑SOIL ROS <br /> / ❑OVER-BORE DIAMETER <br /> ❑WELL# ��1� ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE !�MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:07 <br /> EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS S« �� TYPE OF CASING:❑STEEL)4 PVT OTHER 4PP5SZjC,(j <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL V1#k1ES TREMIE TYPE TO BE USED❑AUGERSXHOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ❑wNo (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> ElSOIL BORING ElHAND AUGER GROUT SPECIFICATIONS /",Ems'r7 (f <br /> ❑OTHER: OTHER � S ❑: APPROX.BORING DEPTH �� �✓ BOLTED TRAFFIC BOX OR El 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 an he work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California La s. / _ <br /> Signed Title/Company S"9-.,V <br /> Com/ �'��O�w��� <br /> Print Name �( E G Date /O v2sr <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: NOV <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY A n ' Q - DATE ISSUED7�T�FGI <br /> - <br /> GROUT INSPECTION BY FINAL INSPECTION BY ISSP 1 i /( � '' ''C I�S <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 /> 1 1561r 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 />