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SAN JOAQUIN COUNTY RECEIVEDENVIRONMENTAL HEALTH DEPARTMENT ��ITE 2a N { 600 East Main Street Stockton CA 95202-3029 �Ll� 0II�f1TI'GATION • . ..1 -",•.P Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sj.qov.org/ehd V EWRONME 1- WELL PERMIT APPLICATION pERMIT/SERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. 2�L AVC E s.L,ik I^ Assessor's Well Location y5J w'SAP S Cross Street �oµS /�/£.* 54rcc+ City STvCK7T0. j Zip 45Z400, Parcel# 1y7_040-/1 Property CIP Tp+h Cf w Owner_MJS , ' -14E C- ef• Address 1955 I w1ls f ` V �fi aw�5 RoA� City c,3r�Ay0 Zip .>�Phone# 6.30-'r✓J;•' y y C-57 Contractor Address City Zip Lic# Phone Consultant/Sub Cntr A.G-E- Address F537 City STOC-ICTor1 Lic#b8oZZ7 Phone ZC1 -V6 ) -10 GIS Coordinates:X Y Township Range Section WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION(CHOOSE TYPE BELOW) El SOIL BORING# OVER-BORE DIAMETER g--tA(j4 C3WELL# Inc Gonl IT ❑"OTHER GROUT SPECIFICATIONS u escl o++ �w COMMENTS: .0.4^40f1 O!\-Sj 1'� w��f S /4w-'I. MW-?- . mty -tit ^4\A/-% I� TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30) ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS I hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and Regulations,and all applicable California Laws. r Signed Title/Company 1080 TiCLT MA►V�Ge� , — Print Name T .1 Date /n DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: Fil F WORKPLAN DATED:_ N4- am an APPLICATION ACCEPTED BY /�AAA,-a1e, DATE ISSUED IZ AREA GROUT INSPECTION BY LLI�M1AAA FINAL INSPECTION BY f M,�t�t��[^� DATE DESTRUCTION INSPECTION BY DATE COMM ENTSICONDITI ONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE -3 -3 2o6`t /L i y/fid sR#61b�o C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC EHD 29-01 10/28/09 WELL PERMIT APP