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Ag`'I" • SAN JOAQUIN COUNTY <br />?ENVIRONMENTAL HEALTH DEPARTMENT TE <br />N. , nfte <br />600 East Main Street, Stockton, CA 95202-3029 �j TION <br />Telephone: (209) 468-3454 Fax: (209) 468-3433 Web�� s.�?r„r3t:� U IV <br />4 <br />WELL PERMIT APPLICATION Eltiltl1po <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS U �t9 l l f�E <br />it>, T <br />Al ���ET? ALTH <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made inC pliance with San <br />Joaquin County Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />177 !�~sY �/✓ U"�% %i�h�f�Assessor's <br />Well Location Cross Street/ City L ��Zi�p Parcel # � rJ <br />Ownertyr��✓ Jd%�C//^% eOZ'Vt,,,A///dfiress <qy/� L' / �C-1 C fJLI�%Go+�Zip %�� Phone r� 0 9 �6� L <br />tractor 7 AX/61 "4ress /;?S 0 ��r' City✓N��/����1p ��`r° 'Lic # 4eJPdKPhone <br />ConsultanVSub Cntr ,�% Address City Lic # Phone <br />GIS Coordinates: X ?,KP Y la/ �pS ��. Township 02 Range Sectiones -,7 ??^�yCc- <br />WORK TO BE PERFORMED: <br />NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ SOIL BORING# ❑ OVER -BORE DIAMETER <br />❑ WELL # ❑ PRESSURE GROUT <br />X*OTHER e/e GROUT SPECIFICATIONS <br />/ / //1j (' A,K� L /- ❑ EXPLOSIVES DETONATING CARD <br />(:r1MMFNTC• `✓� �/ ,SCS /6' J � ���LOl✓ /�/Q OBC:.' . <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 344 <br />f // <br />X <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE 11 E3 MULTIPLE CASINGS ElMULTI-LEVELWELL CASING DIA: 7 <br />❑ EXTRACTION ❑ AIR HAMMER/DRIVEN CASING THICKNESS OW TYPE OF CASING: ❑ STEEL PVC ❑ OTHER <br />❑ VAPOR ❑ MUD ROTARY DEPTH OF GROUT SEAL/ TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE <br />❑ AIR SPARGE/OZONE ❑ PUSH POINT (GP OR CPT) GROUT SEAL PUMPED: ❑ Yes 9No (NOT -E:: MAXIMUM FREE -FALL DEPTH IS 30') <br />❑ SOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS <br />❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH ❑ BOLTED TRAFFIC BOX OR ❑ 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 and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and all applicable California Laws. S�i►/lvi2 �✓�//_ �yE��Q , _ <br />Signed z/6) Title/Company S.9p✓ <br />� - i c <br />Print Name 1��6 "e - �IV G Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY `��r v,�t 7�-/AYE DATEISSUED/`� AREA / <br />GROUT INSPECTION BY `�""—' ' ” "� FINAL INSPECTION BY ^'�L <br />DESTRUCTION INSPECTION BY <br />COMM ENTS/CONDITIONS: <br />DATE <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />All REMITTED <br />CHECK # <br />RECWD BY <br />DATE <br />PERMIT/SERVICE # INVOICE <br />�f 7I <br />8--j. oy <br />S�r� :��a �1•� <br />SR# <br />C-57 WC <br />EHD 29-01 10/28/09 <br />-WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />WELL PERMIT APP <br />