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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT ,JUN 2 G COu <br />.', 600 East Main Street, Stockton, CA 95202-3029IN CouN11�IITl ON <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: WWW.S MENTAL. IT <br />\�X'jgf <br />ttEALTH DEPARTMENT <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 />Assessor's <br />Well Location 32 42- S. 0011600 & Cross Street ldy AVP; City 51'00*toff Zip '(s a 0 t0 Parcel # l i (12-0 2-q <br />Property 40- kt-40 -�'�fci ) <br />Owner GOV® G0(1'tracfort' , Ir1c Address 2-11y1 Navy ur• City s1"bC*t0A Zip 9C1010 Phone # 7A9- 9�jb- b4q?l(u•��Jryyq <br />C-57 Contractor 1 t 1Ji t�1� Address 1��L ` t "� 4 4"k City � iV'� � Zip'1L1� 3 Lic # y '�G 5� Pho � � J <br />Consultant/Sub Cntr M1110 1600" FWIAddress 312-4 M4111 S'r CM 200 City tt MAII4100 Lic # 11605 Phone -SOU- S S 3i 3��it� <br />GIS Coordinates: X '120'4 .6110 i}o.Slo Y 38" 0� 50.01 11, Township IN Range Range IOC Section Za <br />WORK TO BE PERFORMED: <br />AID # <br />NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ SOIL BORING# <br />❑ OVER -BORE DIAMETER <br />❑ WELL # <br />❑ PRESSURE GROUT <br />[� -OTHER V Ipr PrOIV, <br />GROUT SPECIFICATIONS <br />COMMENTS: PGP- 1.4 <br />INVOICE <br />71 <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ,Q HOLLOW STEM <br />DIA. OF BOREHOLE �MMULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA:0.15" WS <br />❑ EXTRACTION ❑ AIR HAMMER/DRIVEN <br />CASING THICKNESS -- (.r TYPE OF CASING: ❑ STEEL JR PVC ❑ OTHER <br />VAPOR ❑ MUD ROTARY <br />DEPTH OF GROUT SEAL 6iL TREMIE TYPE TO BE USED P AUGERS ❑ HOSE <br />❑ AIR SPARGE/OZONE ❑ PUSH POINT (GP OR CPT) <br />GROUT SEAL PUMPED: ❑ Yes JS No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />❑ SOIL BORING ❑ HAND AUGER <br />GROUT SPECIFICATIONS c WeM- ik'CA dfi1* <br />❑ OTHER: ❑ OTHER: <br />APPROX. BORING DEPTH 35 ' ❑ BOLTED TRAFFIC BOX OR STOVE PIPE <br />IW <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment ection) <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 I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and all ais Laws. <br />Signed �i ' - <br />Title/Company Millet" $rOoKK tif1G <br />Print Name 1fifft V 1 Wolf <br />Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY <br />DATE ISSUED AREA <br />GROUT INSPECTION BY <br />FINAL INSPECTION BY DATE <br />DESTRUCTION INSPECTION BY <br />DATE <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE <br />PERMIT/SERVICE # <br />INVOICE <br />71 <br />C-57 WC -WAIVER <br />EHD 29-01 11/5/07 <br />C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />WELL PERMIT APP <br />