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I <br /> a 'San Joaquin q County <br /> z Environmental Health Department-, P SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> UN%IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �-oo <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made'Snliarvith San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. 0 C5; <br /> Asse <br /> WELL LocatJon_&'22_5e&& L//!/L Cross Street Ciiy ZIp, Parce*t <br /> PROPER / � t �p -i�►0 <br /> Owner L- ! Addres C�t� CityZip�Phone# < J O <br /> C-57 Contractor Address City cZip _VjyLic# Phone <br /> Consultant/Sub Cntr ak� Address_'_���y� City. SAA-) Lic# I PhonegIf*-If!•cL1 <br /> GIs Coordinates:X Y Township Range Section <br /> WORK To BE P99FORMED: <br /> % <br /> (NEW WELL 1 BORING jCPT,9EOPR9BE� HYDROPUNCH,HAND-AUGER,OTHER") p DESTRUCTION (choose type below) <br /> / , 601L BORING# 0 OVER-BORE. DIAMETER <br /> WELL# -� 0 PRESSURE GROUT <br /> *Other w*�r / Z� GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYP,g2F WELL I.NAI6LLAI oNl TYPE CONSTRUCTION„§PgCIFIc_ AjIONS <br /> MONITORING �OLLOW STEM DIA.OF BOREHOLE�r 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: r <br /> D EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS`TYPE OF CASING: 0 STEEL VVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ,VAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS f <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH ]BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED ` (if'YES,list speciFlcations 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 in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x J Title/Company �! <br /> Print Name_.__ { /!� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS:. <br /> WORK PLAN DATED: C Application Accepted By Date Issued / Area v f�f`�V <br /> Grout Inspection By - [Date Final Inspection By Data <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> I <br /> SR# 00 tl 2,0:� <br /> i <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit Encroachment docA <br /> EHD 29-02-001 <br /> 6/22/04 <br />