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San Joaquin County _ <br /> Environmental Health Department E <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 952TNIT <br /> TION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.o IV <br /> Well Permit Application AN 0 .9X007 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS ( <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work describe plitn4gei compliance with San <br /> Joaquin County DevelopmentTitle,Chapter 9-1115.3 and the Standards of an Joaquin County En{ironmertfN <br /> '( S <br /> �sZl Parcel#Assessors <br /> WELL Location r /. Cross Street citySTOCt-50 zip�_ <br /> PROPERTY �I.\Ambo1T� l�OC- DR, ��Tlr, B-7 <br /> owner_BlIWKSIb& 61OL-e Address 13 •1 W,12013I91.rd>�;ty SToC 014 ZipftSU7 Phone# ZA 644^ 4922- <br /> C-57 Contractor PG-e*k0R k-f tO-O Address City Zip Lic#,g�9-24hone# <br /> S Y �' 12Ao Te Aut1*'b EX L 'wS 9b X41-Cl Zq ri <br /> Consultant/Sub Cntr � 1 ��SULTIf. j,�OAddress ty �OF�l7(Dic# C42'1 Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WO K TO BE PERFORMED: <br /> EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION (choose type below) <br /> Q SOIL BORING# Q VER-BORE. DIAMETER <br /> Q WELL# ffPRESSURE GROUT Se-MR-)m—)m t l E S1 q-lz� p� <br /> Q'Other GROUT SPECIFICATIONS � rT <br /> A <br /> COMMENTS: -Te �13At;�0io 0112-oU1�D WA(Sel URA�3 CIA—M f (4IS1D�PT}4 <br /> I rJve K PLAN 'bAxT r,> I- -0-7 ,-rOCk4V-� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONSJA <br /> Q MONITORING �OLLOW STEM DIA.OF BOREHOLE b it Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: / <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS <br /> 7—TYPE OF CASING: Q STEEL Q PVC Q OTHER: -rE14P <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL )S Mkf• TREMIE TYPE TO BE USED: 'r AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: V'Q Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Iff"SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS U'�n+�ou 1T �IUTAF-Y 0'- tleK Cla" <br /> Q OTHER: 6?-AD [I OTHER APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> e�,W CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: qcA �S (EI�Qt3�a��'t' C'.RSI0& " J3E}C41-FILA, WtT1-)- 6fO'07 AS LJI 'f�bR�W� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, les and Regulations, and all applicable CaliforniaStateLaws. <br /> Signed x <br /> Title/Company f�ES11.1) / ti��T ��S��LTII�ICj 1f 1G . <br /> T <br /> Print Name SEr'I Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADD R SS: 3�G rod <br /> WORK PLAN DATED: I <br /> Application Accepted ByDate Issued V I tit Are 6 V <br /> Grout Inspection By Date l't Final Inspection By Date 1 <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/SERVICE REQUEST# INVOICE <br /> SR# W to At A 56°l <br /> C-57_ WCC-WAIVER_ C-57 Letter of Authorization to sign permits Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />