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10 San Joa 9 tY uin Coun YEN <br />PA <br />Environmental Health Department REc <br />600 East Main Street, Stockton, CA 95202-3029 ,jON 2 V ZIT TION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />SAN JOAQUIN C IV <br />Well Permit Application ENVIRONM TAL <br />HEALTH DEPART <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 />j� 1 Assessors <br />�u <br />WELL Location 1 7— S e I `�(r� aCLU a -Cross Street lV ( City Zip Parcel# C ?,e)4! / <br />PROPERTY I ii {{ 310 —j Li <br />Owner [ CAA �yy 1 "rtlxlY Sl✓% Address ( 'y �A City � ✓t 'Zip_M! 2 hone# J�'�l ��b��'3`19 <br />C-57 Contractor b'V L k \\�r' Address L rnl�?b ' I`f 's• <br />© 1` Y/ <br />City ic# Phone J <br />Consultant / Sub Cntrl�i �Gr �Y ��()l�S �_-y Address O NZ \'`kO,,A St , SX Zai City ?P�.M Lic# I�Phone# 7I ti �� % i�% <br />GIS Coordinates: X '\ / t>� i l I `-i %ito 1PY �?s "0 )'9), \Y , Township 11\J Range G& Section 19 <br />WORK TO BE PERFORMED: <br />p NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) ,ftJXSTRUCTION (choose type ow# <br />a SOIL BORING # OVER -BORE. DIAMETER— <br />a <br />[] WELL # [] PRESSURE GROUT <br />a *Other �,` GROUT SPECIFICATIONS <br />COMMENTS: 1 eyy\'U\x C3 �i (�1� \lY l f 1 � l Y" u w -(i:�, - <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 1j <br />MONITORING a HOLLOW STEM DIA. OF BOREHOLE__,S " a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ <br />EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS ` r��YPE OF CASING: a STEEL WPVC a OTHER: <br />VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />Q AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />a SOIL BORING o HAND AUGER GROUT SPECIFICATIONSXS <br />a OTHER: a OTHER APPROX. BORING DEPTH Q BOLTED TRAFFIC BOX or O STOVE PIPE <br />` CgN�Dr.U\CTO�RCASING PROPOSED (if YES, list specifications in comment section) <br />/� <br />COMMENTS: Ic lyyy \) Co i ill 1 ` 1 1 W <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, and Regulations, and all applicable California <br />�State <br />lLaws. <br />Signed x - ///--- Title/Company r ' t 4 ` (,��%�—S n IY �� f► P'� 1 <br />Print <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED��:ff//�O ,,� <br />Application Accepted By /"Ar' do-t�.lu�d'� `10 Date Issued6� Area <br />Grout Inspection By ��s/+' d�` Date _% ng Final Inspection By /1✓a.)iaL, rDate 1 a� <br />Destruction Insoection By /G�"r Date 71/v/o0 <br />COMMENTS / CONDITIONS: (01-zke,7' - <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />7a2Fa-14 <br />� <br />��� <br />SR# ��� <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-001 WEB <br />9/11/2007 <br />