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a <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT D 21' <br /> _ h <br /> 600 East Main Street, Stockton, CA 95202-3029 �J IGAE <br /> TION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sigov orc1'd : `� 2l!U <br /> UNIT IV <br /> WELL PERMIT APPLICATION1+EhL�;-i <br /> PFD,p',lrj/, COVI( r r. <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 <br /> Title,chapter 9111 3 and the Standards of San Joaquin County Environmental Health Department. <br /> Well Lo 7211 <br /> `�` ` N� w, �� w, ��,� d �} Assessors n p Q <br /> Property 'I',n. -_ Cross Street City ,f������ Zip`75�,6 parcel ors Ill !_1J/w^ Z"( <br /> Owner �i/11t^L, �, a i�( I Address ��+ GJ/ /SOV1��( 415 r'�cKlIL 0 Zip-!5207 Phone# 'CCGSO aC't'� 7� <br /> C-57 Contractor`N d- � i Address Po � amp `City VtS rft- Zip'?q'.571 Lic# 'fla 07 q Phone 3'? 4 <br /> Cons�ultannVSubCntr14L)E Address-8a )2SAC" ) City Lic# Phone i���ll.�J� 43� <br /> GIS Coordinates:X - 'y —�ZI •ZT5 Township RangeSection <br /> WQRK TO BE PERFORMED: <br /> NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER, HER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> OIL BORING# p ElOVER-BOREDIAMETER <br /> LJ ELL# _ 41 l/ El PRESSURE GROUT <br /> 'OTHER <br /> /Y GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING 07HOLLOW STEM DIA.OF BOREHOLE �,►GGI <br /> ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS <br /> /,j TYPE OF CASING:[3$TEFL �VC ❑ OTHER <br /> VAPOR E3 MUD ROTARY DEPTH OF GROUT SEAL 3y TRE TYPE TO BE BEEUUSED PrAUGERS❑HOSE <br /> (AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ❑No <br /> (N/OTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER ❑OTHER: APPROX.BORING DEPTH`'S -2S �2ot— <br /> .•,^ $OLTED TRAFFIC BOX EI STOVE PIPE <br /> COMMENTS:_1�S /VC 1�I� S CONDUCTOR CASING PROPOSED (it YES,list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. <br /> wSigned ah �� a Title/Company I��1 f� <br /> Print Name PLO. C LNC Date_ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: N. G(/&4,M - �9 <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED Zp—O AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> 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 /> 1,qo w s 3'" 3 2,3 3 7•iZ-off sR# - 398' <br /> C-57EHD 2 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br /> ENCR ACHMENT DOC <br /> EHD 29-01 11/5/01 <br /> FILE C <br />