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��"`'•"' SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT' SITE <br />600 East Main Street, Stockton, CA 95202-3029� 2��g MITIGATION <br />r,7 Telephone: (209) 468-3449 Fax. (209) 468-3433 Web: www.siclo%Wtg/ehd CO�NV UNIT IV <br />�i�r SAN JOAQU�MENT <br />WELL PERMIT APPLICATION H`�HpEPAR�MEN <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 Environmental Health Department. <br />Well Location i % %, (,� �, I IRA%�Cross Street T/tC�Ai.S P—Mb City �LD�_ Zp Assessors <br />/ //� Y ® Parcel # <br />Prorty <br />Owe d ffifr Address ! 8/® f. lff`47TZI�L7ctii ` City 5%Ckrd� Zip p Phone #�ZQ l 9S3 A ` <br />C-57 Contractor �L P10�Q� !jG � Address 3 3y//1/C%�i/ &6--ity /lli_ Uc # if b Phone 1 <br />Consultant/Sub Cntr <br />Address <br />City Lic # Phone <br />GIS Coordinates: X <br />Y <br />Township Range Section <br />WORK TO BE PERFORMED: <br />RECV'D BY <br />DATE <br />NEW WELUBORING (CPT, <br />GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ SOIL BORING# <br />Sq. o <br />0 OVER -BORE DIAMETER <br />WELL # <br />4,/3 O <br />0 PRESSURE GROUT <br />*OTHER V <br />�i C-Af 411C2" <br />GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />i MONITORING <br />a HOLLOW STEM <br />DIA. OF BOREHOLE `A .M MULTIPLE CASINGS IN MULTI-LEVEL WELL CASING DIA <br />0 EXTRACTION <br />❑ AIR HAMMER/DRIVEN <br />e! <br />CASING THICKNESS TYPE TYPE OF CASING: 0 STEEL 0 PVC In OTHER &PAF <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED [] AUGERS 0 HOSE <br />❑ AIR SPARGE10ZONE <br />0 PUSH POINT (GP OR CPT) <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />❑ HAND AUGER <br />GROUT SPECIFICATIONS <br />0 OTHER: <br />0 OTHER: <br />APPROX. BORING DEPTHOI is 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if 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 />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 />Regulatiornia S. <br />ns, a 11 pplicable Califo <br />Signed Title/CompanyAp <br />�/��/D>�./U 7rr�('a�1 i�OL ��P• <br />Print Name Date V 2 4 -o9 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY /fI4444 F Gl < <br />r <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />DATE ISSUED d AREA <br />FINAL INSPECTION BY (Alf ,r �'"/ *rDATE 7 i p9 <br />DATE <br />COMMENTS/CONDITIONS: S �' % -PLC <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE <br />PERMIT/SERVICE # INVOICE <br />Sq. o <br />09� <br />4,/3 O <br />SR#dos J% <br />C-57 WC I -WAIVER <br />EHD 29-01 11/5/07 (WEB) St:_ I( <br />C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />WELL PERMIT APP <br />