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ISCANNED <br /> *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 /> t 1 ��` i Assessors <br /> WELL Location 32LJ'Z S,T, i(,VaCL0 5f" Cross Street `� City s Zip �� Parcel# V ZJG", <br /> OwOnerEye CtXCUCZV� Address CJl I2 (� �/�?,,Cpit�y(y)��Zip� hone# c�7� <br /> C-57 Contractor C '` Address Nva D Oydecity�0�Zip�14aic#-71 J Phone# t <br /> Consultant/Sub Cntrtt p. Addreys�s n� [14'1��NI/ City (05)A Lic# Phone# -1(q_4 �J(-91CC) <br /> GIS Coordinates:XZ1 ����12,1��t Y �0��� Ihl "Iyt ] Township Range Section �2-3 <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 /> JR07VELL# 0 PRESSURE GROUT J`= <br /> -5"Other GROUT SPECIFICATIONS <br /> COMMENTS: Q <br /> N <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS JI <br /> )MONITORING a HOLLOW STEM DIA.OF BOREHOLE �f Q MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL �'hVC 0 OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 3S� TREMIE TYPE TO BE USED: GAUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ,YesNo (NOTE: MAXIM M FREE-FALL DEPTO IS 30') <br /> a SOIL BORING o HAND AU ER GROUT SPECIFICATIONS I SO& <br /> a OTHER:_ THER n I�i APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or XSTOVE PIPE Q <br /> CONDUCTOR CASING PROPOSED /YO (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 Ordinan ules and R ions,and all applicable California State Laws. <br /> Signed Title/Company Cxk *U�-A PAYMENT <br /> Print Name � � Date <br /> 1 RE .,FTVED <br /> DEPARTMENT USE ONLY JAN 17 2007 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 94AN COUNTY <br /> WORK PLAN DATED: VIRONMENTAL <br /> 7!/ HEALT RTMENT <br /> Application Accepted By �' �' �'" '� ve 8� Date Issued � _ ` Area <br /> Grout Inspection By -r — .Date 2/_0 Fie Z g <br /> Destruction Inspection By Date <br /> wCOMMENTS/CONDITIONS: / d cu'* <br /> r/ <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �q7/ ,g 9 � 9_ �� ,2 3 qq Z,�t //12-10 7 SR# <"o �f `� y � -2- <br /> C-57— <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 />