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10 San Joaquin County 0 <br />Environmental Health Department <br />600 East Main Street, Stockton, CA 95202-3029 MON <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />tF <br />V <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 />r Z t.1 �, S _ Assessors Z <br />WELL Location �I l�� Cross Street ' ( City Zip Parcel# <br />�► <br />PROPE TY 1 q_�aSfG(O (►4r+G ��� <br />Owner LO'& ( \' ✓i. Address 3-111 oxy � City �'Lt4AZip_ 52449 hone# �%������-3��� (�jl►,� <br />C-57 Contractor \`� n ul \���Address q'V kV CityW " t Zip�� ic# � ' 7 Phone#13 <br />Consultant /Sub Cntrj\N �r �)\j Address a\VZ �` O iA St , S'� za) City ?,eK 1 Lic# V 3CZ& Phone# 7 ti —9-0 <br />i <br />GIS Coordinates: X "\ W� � �'l2-I `-i(?.j(o �Y .� ! �(� )�•l� \ ,Township l fRange � Section a <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING <br />0 SOIL BORING # _ <br />0 WELL # <br />0 *Other <br />COM <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />STRUCTION (choose type <br />OVER -BORE. DIAMETER <br />[] PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />LCA— '-� <br />PE OF WELL INSTALLATION TYPE CONSTRUCTION,SPECIFICATIONS f, <br />ONITORING 0 HOLLOW STEM DIA. OF BOREH&E 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ =. <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS l✓ TYPE OF CASING: 0 STEEL VC 0 OTHER: <br />0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE US D: [] AUGERS [] HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS A <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH Ll Z 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />1 \ CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: �ti�L k�tZ 1 ��4��(�`VUL�L <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,.Rules and Regulations, and all applicable California State Laws. <br />Signed x / / , `` Title/CompanVA y n / <br />Print Name <br />�� k Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILEADDRESS: <br />WORK PLAN DATED: i <br />Application Accepted By Date Issued Area <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT / SERVICE REQUEST # <br />INVOICE <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 />