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*San Joa uin Count 'OSCANNE�-Uq Y <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 /> I , -(�r��M/�) 7 �/j� Assessors <br /> WELL Location "1� S'�I -QVM' Street City _?�L� �Zip Parcel# <br /> Owner � <br /> ER �� o � Address City_< ZipPhone# <br /> C-57Contractor U, ('l�pfI 1501 Address V i (]/,, ow <br /> �_LC�ity_tzZip��ic#-'h3 # 1U� 1 <br /> Consultant/Sub Cntr-1 1 �+���1 1, +Address t 5lll� o�tl.Y II"'lr 11 ` i'ty(O Mei, Lic# Phone#719—l`"l3�—�' 10D <br /> GIS Coordinates:x ,02--o , ,Y l3,I1 I b'!jDPS!I ,Township V Range �� �i Section d <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> -WlNELL# 61)W- A- a PRESSURE GROUT (� <br /> D*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING a HOLLOW STEM DIA.OF BOREHOLEja' a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS-!�-0 Lq TYPE OF CASING: a STEEL XPVC a OTHER: <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 3 Q 5' TREMIE TYPE TO BE USED: GAUGERS a HOSE C� <br /> AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes a PV (NOTE: MAXIMUM FREE-FALL DEPTH� IS"30' <br /> a SOIL BORING a HAND AUGER�y GROUT SPECIFICATIONS ' A 0 w ��I <br /> a OTHER: OTHER Sall�L APPROX.BORING DEPTH a BOLTED TRAFFIC BOX orXSTOVE 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 /> I hereby certify that I have prepared his application and that the work will be done in accordance with San Joaquin <br /> County Ordinan7/711,�4� <br /> , R es and R ions,and all applicable California State Laws. <br /> Signed x c Title/Company l 1/r�SU <br /> Print Name Dated 0 11. NA ENT <br /> D ARTMENT USE ONLY RECEIVED <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2007 <br /> WORK PLAN DATED: <br /> NTY <br /> Application A e u Gs �� �" Date Issued ���710 SAN JOAQUIN COAL <br /> Grout Inspect Dat �;S/�3' Final inspection By r �� ate IARTMENT <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# <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 />