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• :i San Joaquin Count ✓ i1 NED <br /> Environmental Health Department <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> n ^ p��,, Assessorsl.� <br /> WELL Location -%�u` � Cross Street U City Zip Parcel# V l <br /> PROPERT�0 `B CM �6 �}-y q ' A (,,, �q 'l/� �6do <br /> Owner I UUc/r��W���I��'V t/" ` Address 0�7 �IN��'. (`1. City 10 y Zip/Phone# au l —'?-L6 <br /> �1 l�(,l /n <br /> C-57 Contractor l-ut�(.,(J2(i I 1 111 Address 36Z-t�jt Llc ] City ip-I`J c# Phone#C1� 6c)—I(x(c <br /> Consultant/Sub Cntr Address ; I'&A � City Lic# Phone#�_�'I' 10 <br /> I �^ �I Q1 1. ", <br /> / Z3 <br /> GIS Coordinates:X 7 CLof� Y��I l UJ �l.,y� ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> SOIL BORING# a OVER-BORE. DIAMETER <br /> jy6ELL# VY W)'1A- 0 PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING a HOLLOW STEM DIA.OF BOREHOLE n MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS sto t' TYPE OF CASING: 0 STEEL V"PVC 0 OTHER: Q� <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL S1 TREMIE TYPE TO BE USED: GAUGERS a HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes p No (NOTE: MAXIMUM FIR_EE_-FALL DEPTH IS 30') <br /> a SOIL BORING HAND AUGER GROUT SPECIFICATIONS ,fin <br /> a OTHER: OTHER I G APPROX.BORING DEPTH I pe a BOLTED TRAFFIC BOX or ,STOVE 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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, 0 pplicable California State Laws. <br /> Signed x �/71vrti <br /> Title/Company Cmw B <br /> L <br /> l / ✓� Date L1' PAYMENT <br /> Print Name <br /> D PARTMENT USE ONLY RECEIVED <br /> SITE MAP IN UNIT IV FILE,ADDRESS: '"N4 7 2007 <br /> WORK PLAN DATED: <br /> Application A By cJGL07� ✓Y/ �6 Date Issued ��0 7 Area SAN JOAC]NIMENOTANTM <br /> Grout Inspe ion B 4�?^ Date Final Inspection By �� + ate / Z. DEPARTMENT <br /> Destruction Inspection y 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 /> ,�'v7/ ,9 y. D� 02 3 qSR09(# Ll 5 y ' <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />