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San Joaquin County 5 ( ; _; I `,; <br />Environmental Health Department l� " L' a TE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 P PRM►TIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: kr",v.sjgov.org/ehd 9 2�". <br />UNIT IV <br />i_IT[ HEA( T: i <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 Standards of San Joaquin County Environmental Health Department. <br />Assessors <br />WELL Location �J� `j 1,16, %fir <`f ?C1-� Cross Street _ (�5 City `�ti .� 1`�� (� Zlp _t � oParcel# I t _- -� 50 - OLt <br />PROPER?,�_ <br />Owner h�t/�(� LQ��ir')ri Address_13.�S lL�, i-Yt°.YY1, City c; k -Ern Zip 5 '. one# i}� <br />C-57 Contractor(��A � \l\ 0,C)i _AddressC6L. �l(X�Y% eco'o City �� 1' h" L Ztp'(4S`43 Llc# `I �' l IGSPhone# LC( O- 313 ' S�� <br />onsuttant/Sub Cntr_ Okl7Ci_ Q- l � � nkLGgkddress 1 i;1 } `�f City M&Lc AT Lic# — Phone#«Cf `�-).7 - L{((9 <br />GIS Coordinates: X 'y Township Range Section <br />WORK TO BE PERFORMED: <br />U NEW WELL 1 BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) a DESTRUCTION (choose type below) <br />0 SOIL BORING # ;e<VER-BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />)g'MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 17 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />a AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />n SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br />a OTHER: _n OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: 5Lt L � k(' c <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 in accordance with San Joaquin <br />County Or les an gulatlons, and all applicable California State Laws. <br />Signed x TitlelCompank��, WQn,L- (�I/��i�,f///yam <br />Print NameDate <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By Date Issued r 20103 A a <br />Grout Inspection By Date Final Inspection By � Date <br />i <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: t a <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT / SERVICE REQUEST # <br />INVOICE <br />D <br />i7g <br />z S R# ;. <br />C-57_ WC --WAIVER_ C-57 Letter of Authorxatir �10 si jn permit_ Encroachment docCHD jy,�� <br />22104 29-02-001 �✓/ ,,> l� L v? q 5 L✓Y cY <br />