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San Joaquin County 0PAI,���l� <br />Environmental Health Department RECeti\JE S <br />600 East Main Street, Stockton, CA 95202-3029 J (j '64AITI ON <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehdUN 2 <br />SAN JOAQUIN COUN <br />Well Permit Application ENVIRONMENTAL <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I-IEALTH DEPARTMENT <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 />Assessors <br />WELL Location r �� <br />�`'(Z S l%� ��L �CrOSS Street 1 � City ,I�—Zip��Parcel# <br />PROPE TY '1` ►,�y, ''""�,/�� <br />Owner C' tnl rur i�VY, Address �� ( NCity S� :In Zip 49 hone# <br />C-57 Contractor \\� Address '"1� �"� � City i h� �Zipt' ' lLic#�A f� Phone# <br />Consultant / Sub <br />GIS Coordinates: X '�� U� `t Lt ` j0.�(o Y i� �� �Y , Township l I J Range <br />G � <br />Section a <br />WORK TO BE PERFORMED: <br />D NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) �STRUCTION (choose type # <br />D SOIL BORING # OVER -BORE. DIAMETER) <br />0 WELL # PRESSURE GROUT <br />0 *Other GROU SPECIFICATIONS <br />COMMENTS: i e vv*\"\)G C)4 ��,U%1� 1(�a, l i Yywj -- <br />S L/ <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />t <br />MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE / 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />D EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 0/1_ 0 TYPE OF CASING: D STEEL D PVC D OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE D PUSH POINT (GP or CPT)GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />D OTHER: D OTHER APPROX. BORING DEPTH D BOLTED TRAFFIC BOX or D STOVE PIPE <br />COO CTOR C ING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: A1J'�v V� l\ Clw� <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 a and Regulations, and all applicable California State Laws. <br />Signed x11 Title/Company t 4) (' f����� nV `Y iAA i� �' I • t_ <br />Print Name �� k Date 3��} <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED:q��� ��,,(( <br />Application Accepted By 4WL. K-. �� �6gV Date Issued Area <br />Grout Inspection By ''A d , 7 lDo$ <br />Date Final Inspection By h te�/y <br />Destruction Inspection By r�G �* ?�.' ZW Date ldw� <br />COMMENTS / CONDITIONS:_ n'4 — AV-I{ea"-e <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT/ SERVICE REQUEST # <br />INVOICE <br />yY7; <br />$ a <br />sR 0 d -L , <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 />