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1",4-r �Da <br />San Joaquin County D <br />Environmental Health Department &/V"04JT 200600 East Main Street, Stockton, CA 95202-3029 AT ,� <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd U�C jN <br />Well Permit Application �����,lll��� <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 Location3a��.�n). ) A&y^rntr L"e- Cross Street City S� OG�e�r(w Zip 4�id.�4 Parcel# 1&P-3Z)L& <br />PROPERTY 93447 <br />Owner�,YO OIL CO 4.OR P Address 'PO BOX I S 33 y City`PA50R0&E&jp'. Phone#^ _ _ - <br />/CLe,nL�.o <br />C-57 Contractor C�.Se a Address3�3� llb,,lpp _,r. City CDCve Zipck�ic#��Phone#(A\1�38-116 <br />01, <br />Su:-�G �O CCa+nc.L.o <br />Consultant / Sub CntrSAddress 6'PIXR& City LacA, Lic#A KIALA(AFPhone#L60 <br />tIli <br />GIS Coordinates: X �o�� 1{ �AI Y Township Range Section <br />WORK TO BE PERFORMED: <br />ANEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />)R GVELL # M W —'1 S 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE 11 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS S 0 TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS )'HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 'Yes 0 No (NOTE: MAXIMUM FREE -FALL DE/PTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS �t til ��jGW�GV�-1- lTr�lA <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH_ I 'BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED n (if YES, list specifications in comment section) <br />COMMENTS: <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 0-4;; ^^^c o. I-- --A nnri sill applicable California State Laws. s <br />Signed x�� —Title/Company 1p1'D �CC <br />4"7S� �UG60P <br />Print Name J{*5c� ._ _ Date <br />DEPARTMENT USE ONLY t <br />SITE MAP IN UNIT IV FILE, ADDRESS: �2,02- )&, Harnth er Ldfn t <br />WORK PLAN DATED: AUc1 U.S-f 3D. of D i <br />Application Accepted By i G Date Issued Areae <br />Grout Inspection By Date 3-&-0 E Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS:Wbn;fVrji7A MW- /:3 <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CH KI# <br />REC'D BY <br />DATE PERMIT IRVICE REQUEST # <br />INVOICE <br />1,�G1 <br />890U <br />gok 60 <br />2 <br />/.2 -/a -o SR# d�S29/l <br />C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroac m oc <br />EFID 29-02-001 WEB IliN <br />9/11/2007 \S �. <br />01135_5 <br />C <br />F F -9— <br />c <br />