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SAN JOAQUIN COUNTY <br />. ENVIRONMENTAL HEALTH DEPARTMENT,10 2 U <br />600 East Main Street, Stockton, CA 95202-3029nN coUNT 11 TION_ <br />.% Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sRO.4 <br />AENTAI_ <br />rl.{Ep,LTH 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 _3432- C• LI PorddD St'Cross Street iV j Ay?. City S-WCA-4011 Zip qSZOID Parcel # IlTT020-Xq <br />Property 3i0 ,44 t <br />Owner CbVO (3n-fr41(JVr5_, InG Address -xt1 Nab Dr. City qq(O -ton Zip 016WLp Phone# <br />C-57 Contractor 019 t) AddressT UW -e City Vv `w / � f Zip 1-M3 Lic # `��5 � Phone <br />Consultant/SubCntr WlliicX Brooks OV.Address 3i2j Mair l;ri;jam 200 City Lic# 130s110 Phone 119-a0-4Ns1 <br />GIS Coordinates: X -120 +{Z -SIO <br />a �'} , Y 8$" 0:60 0144 ,Township iN Range (oii Section Z <br />WORK TO BE PERFORMED: <br />JKJ NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ SOIL BORING# ❑ OVER -BORE DIAMETER <br />❑ WELL # ❑ PRESSURE GROUT <br />VZ*OTHER V4 00r Prfte, GROUT SPECIFICATIONS <br />COMMENTS: f 6 p - .ZAr <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING RHOLLOW STEM DIA. OF BOREHOLE V 9LMULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 0.105 <br />❑ EXTRACTION El AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL @3 PVC ❑ OTHER <br />P9 VAPOR ❑ MUD ROTARY DEPTH OF GROUT SEAL SCCA TREMIE TYPE TO BE USED U9AUGERS ❑ HOSE <br />❑ AIR SPARGE/OZONE ❑ PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: ❑ Yes [XNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />❑ SOIL BORING ❑ HAND AUGER <br />❑ OTHER: ❑ OTHER: <br />COMMENTS: <br />GROUT SPECIFICATIONS «eRt klthire <br />APPROX. BORING DEPTH 89 t ❑ BOLTED TRAFFIC BOX OR ,W STOVE PIPE <br />CONDUCTOR CASING PROPOSED 00 (if YES, list specifications in comment section) <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />I hereby certify that 1 have <br />Regulations, and all appli <br />Signed <br />this application and that the work will be done 1 accordance with San Joaquin County Ordinances, Rules and <br />ornia Laws. <br />Print Name Qom" 61541101T <br />SITE MAP IN UNIT IV FILE, ADDRESS <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY _ <br />COMMENTS/CONDITIONS: <br />Title/Company M1111 ' <br />DEPARTMENT USE ONLY <br />s tMV1r004tenTal , Inc <br />DATE ISSUED <br />FINAL INSPECTION BY <br />AREA <br />DATE <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 />PERMITISERVICE # <br />INVOICE <br />117e <br />g � <br />lfgT — <br />g <br />I a� f a r <br />SR# 0-Wj <br />C-57 WC -WAIVER <br />EHD 2M1 11/5/07 <br />C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />WELL PERMIT APP <br />