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0 <br />SAN JOAQUIN COUNTY 46 04 <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.s0gov.org/ehd UNIT IV <br />51 S <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 Develop n Ti le, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessorsd� <br />Well Location / Cross Street City Zip ��Parcel # �� <br />Property-.,,/ — <br />Owe���✓ 0,-f e lAl e'.YA1 ress '; /0 //i92Ey 0!✓ ��E'1400 Zip 9. PY.IIhoon <br />C-57 Contractor 4x?_1_6yY-/IAVdss /- O *69--e <br />ConsultanVSub Cntr <br />Address <br />City Lic # Phone <br />GIS Coordinates: X <br />1 <br />Y /� % CY'�� <br />�/ O <br />!� Township -2��l�r/ Range SectiorF <br />11V9RK TO BE PERFORMED: <br />NEW WELL/BORING (CPT, GEOPROSE, HYDROPUNCH, HAND -AUGER, OTHER*) ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ SOIL BORING# <br />❑ OVER -BORE DIAMETER <br />❑ WELL # <br />4;E <br />❑ PRESSURE GROUT <br />*OTHER <br />ZZ <br />-�� GROUT SPECIFICATIONS <br />COMMENTS: <br />/A� A <br />�1�/V <br />r"�"" — lk <br />TYPE OF WELL <br />MONITORING <br />El EXTRACTION <br />❑ VAPOR <br />INSTALLATION TYPE <br />HOLLOW STEM � <br />9AIR HAMMER/DRIV07,,N <br />/ ❑ MUD ROTARY <br />CONSTRUCTION SPEVIFICATIONS <br />DIA. OF BOREHOLE ! ❑ MULT L CASINGS EIMULTI-LEVELWELL CASING DIA: <br />CASING THICKNESS ���� � M <br />TYPE OF CASING: ❑STEEL �C El OTHER <br />DEPTH OF GROUT SEAL /)t464Q1041VIIE TYPE TO BE USED ❑ AUGERS HOSE <br />❑ AIR SPARGE/OZONE <br />❑ PUSH POINT (GP OR CPT)_ <br />FREE -FALL DEPTH IS 30 <br />GROUT SEAL PUMPED.�40 Yes ❑ N/oo ((NNOTE: MAX ') <br />❑ SOIL BORING <br />ElHAND AUGER <br />XIIMUM <br />GROUT SPECIFICATIO S /�/Gr7 / G 7����� <br />❑ OTHER: <br />❑ OTHER: <br />APPROX. BORING DEPTH n BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />CONDUCTOR CASING PROPOSED (I YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: <br />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 work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and all applicable California Laws. <br />Signed Title/Company S,aj�►/�(}/�G/j/✓ ���/�'f `/ _���� S c2 /D <br />Print Name %� %�C/�� `�'�©G Date a F D <br />DEPARTMENT USE ONLY <br />ll <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: <br />DATE ISSUED <br />If FINAL INSPECTION BY <br />DATE <br />23 <br />Y/i O <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY DATE <br />PERMIT/SERVICE # <br />INVOICE <br />C-57 WC -WAIVER <br />EHD 29-01 11/5/07 (WEB) <br />C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />WELL PERMIT APP <br />