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1 a\ San 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 I iA11T 10/ <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 /> L6RRi HLZ!//a✓ ' �- -1SeO �iPi9CY 95.E 7,Assessors� ® D <br /> WELL Location Cross Street City Zip Parcel# $ 3 p <br /> PROPERTY L �/i✓� �,�l <br /> Owner �✓ S� Address ��/® irA�2ra7 City ���&%" Zip �'{11)oh ne# 09 <br /> L�r ` G Cao CG�4 9 <br /> 3 —//6 9 <br /> ,"� D / <br /> C-57 Contractor Address �;ty Zip Lic# Phone9i <br /> �` / 7/ 75'/0 <br /> Consultant/Sub Cntr L-1 �' J' Address Sj�7 /���Y G�City�e�f Lic# Phone# <br /> GIS Coordinates:X 'Y —Township .� .50Z ryg- Range 3 Section �6 <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) Q DESTRUCTION (choose type below) <br /> /` ®SOIL BORING# a OVER-BORE. DIAMETER <br /> ®WELL# '//q a PRESSURE GROUT <br /> *Other _ GROUT SPECIFICATIONS <br /> COMMENTS: 2'/�,>!�/.i-dLA%/!!I✓ rJ,cli✓Ei✓ /�//°CE" 'P'g0e6` <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING --'fiOLLOW STEM DIA.OF BOREHOLE ®MULTIPLE CASINGS ®MULTI-LEVEL WELL CASING DIA:H � <br /> ®EXTRACTION ®AIR HAMMER/DRIVEN CASING THICKNESS NfA TYPE OF CASING: a STEEL ®PVC ®OTHER: <br /> VAPOR ®MUD ROTARY DEPTH OF GROUT SEAL .5'1—"/r TREMIE TYPE TO BE USED: ®AUGERS a HOSE <br /> AIR SPARGE/OZONE ®PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30' <br /> Q SOIL BORING ®HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: o OTHER APPROX.BORING DEPTH �/r ®BOLTED TRAFFIC BOX or ®STOVE PIPE <br /> p CONDUCTOR CASING PROPO E ® (if YES, ist specifications in comment section) <br /> COMMENTS: /J EN/I�JJ// G� crEA"C 80-Y70P? 07C 1 0R&Zd <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 � Title/Company S'EN/4/ Uv/G <br /> Print Name /®/ ��C/`� y G R v`L Date /O <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> �c�+ Date Issued � <br /> Application Accepted By �r s'° �L��f t-- //���� 7 Area- <br /> Grout Inspection By ami i Date WZ110,8 Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <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 />