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San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />SITE <br />POITIGATION <br />UNIT IV <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 />Assessors . . <br />WELL Location 3U N , E�yCtV�� 5' , Cross Street MI K2 V Akt, City Str-'c k IrC: k� Zip _Parcel# <br />PROPSg,T�,Y <br />er C�/ <br />Own16rr/'t $ Steob0 U Address '794 7 E 6lly4AXJ 2( City zip- g2 2Vt-, Phone#45/G5 266 J <br />C-57 Contractor. he_ n iil St'�U —Address)qv ftpL>J(' v (R City 666 i`W?-Zip ! Sj Lic# S 10' Phone#(/0Is)3d -` R00 <br />Consultant / Sub CntrAAl)C.vvi Lod Clt'CNV Address & 3 7 S liy-y Pd City � k-iCn Lic# Phone# <br />GIS Coordinates: X Y Township_ Range _ Section <br />WORK TO BE PERFORMED: A <br />NEW WELL /-B-ORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) �> <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />0 WELL #0 PRESSURE GROUT <br />Other 0 - / go, ; ta�-5 GROUT SPECIFICATIONS ` <br />COMMENTS: �` J CPT - IZwlf/p(( bi��v)j ice-uflop 5 --- <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLCW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: AJA- <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS /J//4 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 S -IL BORING 0 HAND AUGER GROUT SPECIFICATIONS af-'1/MLac.-(J C Thr <br />OTHER: oPr 0 OTHER APPROX. BORING DEPTH ?< S f 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED ,V)A (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE E30RINGS 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��~� <br />�--x-� <br />Title/Company �1 G`� i S <br />/.ttCu�CRr1� % CL r�atiJ <br />Print Name I ) o, int f <br />/ <br />�-i Kc,, C', C k <br />Date <br />INVOICE <br />350 ► <br />DEPARTMENT USE ONLY <br />'01", 89. 00 <br />SITE MAP IN UNIT IV FILE, <br />ADDRESS: 30 8 I\) <br />0 r +j1 CT ra rl cS+ree� <br />WORK PLAN DATED\:, <br />0 C, -i- n Io e y- 20, 20 <br />l) 4 <br />Application Accepted B _ V <br />► c,+ -or t (:��jLl��, i�C�(j!'7? <br />�l ( Date Issued Yri <br />2004 Area S <br />Grout Inspection By iG (�i6 <br />j�Date / 2,11 <br />inal Inspection By <br />` <br />Destruction Inspection By <br />Date <br />COMMENTS /CONDITIONS: <br />Aaklariee-rn o -f o -F <br />2 CPT b rinaI s C <br />T- I and CPT - <br />ACCOUNTING ONLY: AID# FAC# <br />C-57 <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PER RVICE RE EST # <br />INVOICE <br />350 ► <br />89.00 <br />'01", 89. 00 <br />SR# 004662,5-- <br />040G2S <br />C-57WC -WAIVER C-57 Letter of Authorization to sign permit _Encr oc <br />EHD 29-02-001 <br />6/22/04 <br />