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San Joaquin County <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 /> JAssessors /i `�{ <br /> WELL Location J a-!lr/N�"" Cross Street U CityAAI�w Zip Parcel# -4 6Z�v , <br /> OwnnerERPROPItJU C/ CM <br /> I����✓"'� '` Address.` t"ay'°1 �. City q0 Zip Phone# D-y L�-qfb— <br /> C-57 Contractor 1 vim( 6'I Address JI7 ��VY'����`-r,k ®1�,,C`/ity ipq!2_ Phone#O( 4130-44 <br /> 4 <br /> Consultant/Sub Cntr lU� Address l� AA V IYi uu "I" Y�+pW}City Lic# Phone#�_ !� <br /> GIS Coordinates:X�t 5'07001s- <br /> ,Y `a!�' �I� ,�,Il Township 01v Range CD Section �� <br /> WORK TO BE PERFORMED: t <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") D DESTRUCTION (choose type below) <br /> SOIL BORING# D OVER-BORE. DIAMETER <br /> k-VELL# D PRESSURE GROUT <br /> D*Other GROUT SPECIFICATIONS <br /> COMMENTS: ��?� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING D HOLLOW STEM DIA.OF BOREHOLE D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: I_ <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL PVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEALS TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS 1 <br /> D OTHER: OTHER I G APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or TOVE PIPE <br /> CONDUCTOR CASING PROPOSED IN I U (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 Ordinances, R a d Re ulatio ,and all applicable California State Laws. <br /> Signed x ( Title/Company (�%1/l�Li_��✓er�1l'-l— � 7 <br /> Print Name L Date t7A11ENT <br /> ® PARTMENT USE ONLY F�ECEIVE® <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 7 2007 <br /> WORK PLAN D TED: <br /> Application A BDate Issued 7 O� Area SAN JOAQUIN COUNTY <br /> NL1/1RONMENTAL <br /> DEPARTMENT <br /> Grout Inspe ion Date ��C �JFinal Inspection By ate / 2�' <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 /> 1�lq?/ 99 ya WO 02 3 99 —7 / //,2/f}i SR# 00 4 5 L <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 />