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San Joaquin County <br /> Wel <br /> r� <br /> fi )V f Eu vi ~onmental Dealt Department SITE <br /> TIGADPN <br /> dry � s3f�-:.' '� <br /> 304 East Weber Avenue,3rd Floor Stockton CA 95202 <br /> (209) 468-3449 l7trx: (209) 468-3433 Web: www.sjgov.org/e:hcl <br /> UNIT I <br /> z <br /> Well Permit Application 'AID LG <br /> NON-REFUNDABLE PERMIT EXPIRES 9 YEAR FROM DATE ISSUEDj 'f% a1'_ � <br /> «rS(_ <br /> Application is hereby made to San Joaquin County for a permit to construct andtor install the work described. This applOTERM made jn,et pRnce with San <br /> Joaquin County Development Title,Chapter 9-1 115.3 and the StandNfr� San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location ' Cross 5 �'� City �"}h�d Tip 'i5 3>o Parcef# Zt O { <br /> PROPERTY <br /> Owner 2i Address �'> V� She ru,$_City �Zip qT5 50 Phone# <br /> 0-57 CDntractor Address City U,*�244M Phone#t°1 t 6 7 E Do <br /> Consultant/Sub Cntr �v�eo ��� � Address 2--�-''C' k-1 �City_ �Lic# _Phone# �ZD��r-55--cc,(� <br /> GIS Coordinates;X---- _ , Y Township Range_,_ Section r <br /> WORK TO BE PERFORMED: <br /> JNEW WELL/BORING (CPT,GEOPRORF,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> tt SOIL BORING# <br /> 0 OVER-BORE. DIAMETER <br /> O �e S GROUT <br /> a <br /> -- " ther 6a GROUT GROUT SPEPE CIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Z MONITORING HOLLOW STEM DiA.OF BOREHOLE, rr d MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_ 40 TYPE OF CASING: ji STEEL VC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_!�; TREMIE TYPE TO BE USED; j]AUGERS j]HOSE <br /> 0 AIR SPARGE1 OZONE ji PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No ( TE: MAXIMUM FREE-FALL DEPTH 15 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIRCATIONS <br /> 0 0THER: ___._0 OTHER___.— APPROX,BORING DEPTH 0 BOLTED TRAFFIC BOX or TOVE 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 in accordance with San Joaquin <br /> County aces, Rues and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Data <br /> DEPARTMENT USE ONLY Ui <br /> SITE MAP IN UNIT IV FILE, ADDRESS: rA1 t! <br /> WORK PLAID DATED: —C) -5 <br /> Application Accepted By_-_--____ Date issued 'Q Area <br /> - <br /> Grout Inspection BY Data — Final Inspection By Date <br /> Destruction Inspection By Date Y <br /> COMMENTS t CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE "PERMITVICE REQUEST# INVOICE <br /> � <br /> C-57 WC_ -WAIVI=R� C-57 Letter of Authorizatior to sign pet'mit Encronchment clot _/4 <br /> EHD 29-02-001 <br /> 0/22104 <br />