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0San Joaquin County • <br />Environmental Health Department <br />600 East Main Street, Stockton, CA 95202-3029 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />4-e <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 />GGPiP� ft�tlr/�✓ `Aj✓�f/G �Seo �iP/9CY 9S� 77Assessors <br />� <br />WELL Location Cross Street City � Zip Parcel# Jr 3 CO -7 0 / 0 <br />SJt <br />PROPERTY <br />�pG✓li /o Addres� ��� � �EUy�t .f/ lin �Phnnait -1 V G P f �6-4-4 <br />e#v Call j 9 s-7 V� <br />C-57 Contractor c r� �r Address 3 City Zip Lic# PhoneP5 V4 <br />Consultant / Sub Cntr �C C1�% �� Address 3��7 / ,. City „7S/ e <br />L'ic# Phon# ! d ' vb — LZom <br />GIS Coordinates: X Y Township Ste^' Range 3 Section �a <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) p DESTRUCTION (choose type below) <br />Q SOIL BORING # a OVER -BORE. DIAMETER <br />Q WELL # '/A a PRESSURE GROUT <br />*Other _ GROUT SPECIFICATIONS <br />COMMENTS: .�/dt!�/A-dL iF%/d!✓ efA1 ^--ew /tel'-oer Pgolw jwe 4/fs / vl,75ewv/ �r i✓�t^(-� <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING —FOLLOW STEM DIA. OF BOREHOLE a n MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: HW/0' <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS—;eV-/--4 TYPE;PF CASING: 0 STEEL 0 PVC a OTHER: <br />a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 5',g TREMIE TYPE TO BE USED: Q AUGERS o HOSE <br />a AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: p Yes No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS N �T LE�CO���C� / ��'�rLi e <br />a OTHER: a OTHER APPROX. BORING DEPTH �/� 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br />p` CONDUCTOR CASING PROPO E G (if YES, lis specifications in comment section) <br />COMMENTS: /F3 `N%!�%►l// Fir �EA'L /QJ���%li%Y% O� �/A JdJ�!/SG�i�� A/CG� <br />r <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, R and Regulations, and all applicable California State Laws. _ <br />Signed x JE/% t Title/Company s-Ee,Ui//G e;i of c — i-dL/v `✓�'J� <br />Print Name A" AyeyA Z' e�R6f I- Date /O , <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By �r Date Issued / ,g 0 7 Area <br />Grout Inspection By .r4`1 .. Date Final Inspection By a.4cr ate V -11Z 47A <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />9, <br />SR# (z0059 _5 2 <br />C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br />El ID 29-02-001 WEB <br />9/11/2007 <br />