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� r'r San Joaquin County �� U r 'y <br /> FnviaRonnaea�ta HealthDepartment SITE <br /> 304 East Weber Avenue, 3�'d Floor, Stockton, CA 95202 C �t ,Nf <br /> �[ kofl <br /> ION <br /> (209) 468-3449 Tax: (209)468-3433 Web: w1vw.S.l90v.0r9/ehd UNIT V <br /> Well Permit Application AUF, <br /> NON-REFUNDABLE PERMIT EXPIRES'I YEAR FROM DATE ISSUED ENV)RUMM-N-1- HEALTH <br /> Applicatiorn€s hereby made to San Joaquin County for a permit to construct and/or install the work described. This aFt4JEWri FRV ,Et@ipIiarice with San <br /> Joaquin County Development Title,Cha ter 9-111E.3 and the Standards o#San Joaquin County Enviranmentat Health Department. <br /> Assessors <br /> WELL Location _Cross Street ���City t �{-�pro _Zip �C�3 3a Parcel# 2l3 <br /> PROPERTY <br /> Owner--V-%✓tee, -Address <br /> w. kc Cit Lr� �U `t533d PYtane#C-57Contractor V W D'it I,, Address 9,0• �5gx At 6 city L5-1-±or Zip%tA(Lic# Zf7gv Phone s6� -A(L� U <br /> ConsultantlSub Cntr _ o 1'+=-• _Address �bY(D t1J.�IIIL�L City af6"'Y Lic#__. _ Phone# (Zf i7 s35 (�G IL7 <br /> GIS Coordinates:X _ Y ,Township_ Range Section <br /> WORK TO BE PERFORMED: <br /> N NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) a DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE, DIAME T CR <br /> 0 VVFLL# 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING OW STEM ]IA.OF BOREHOLE s 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTtON f7fRHAMMERIDRIVEN CASING THICKNESS__ TYPE OF CASING: a STEEL VC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL �TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> 0 AIR SPARGLF OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes 0 No (NOTE: MAXIM PM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPEC€FICATIONS <br /> 0 OTHER' 0 OTHER_______ APPROX.BORING DLPTH LZ- 0 BOLTED TRAFFIC BOX o/i, <br /> TOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,Ilst specit cationomment 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 dome in accordance with San Joaquin <br /> County Car "nances, Ies and Regulations, and all applicable California State Laws. <br /> Signed x .+�"^�- TAle/Company <br /> PrirnI ame ��/CCs� ! ( PGA--tC077 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED, <br /> Application Accepted By.., _ Date Issued <br /> Grout Inspection By mmm Dafe _ Final Inspection BY <br /> Deslruction Irnspect#on By pate <br /> COMMENTS i CONDITIONS: <br /> ACCOUNTING ONLY_ All)# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RFC'D BY DATE 4PERMIT 3 SERVICE REQUEST# INVOICE <br /> SR# � <br /> C-57___-_ WC -/-WAIVFR_____ C-b7 Letter of Authorization to sign permit_ E'er ncroachrnent dac_ <br /> FtID 29-02-001 <br /> 6/22JC14 <br />