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San Joaquin County <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 GATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd �' a <br />���'• .. it <br />Well Permit ApplicationS1 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l'% ( <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 compliande With -� T <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />/) C ` Assessors p G <br />WELL Location 15771 5c .(1t IfCCLAy1 t'grll Cross Street City Zip I � ;52kParcel# <br />PROPEFZTY 2;Pilo QQ ''i'(t`ap 2C / <br />Owner , Address 1%IS-r)Jltl t � City_W(INAt Zip `t Phone# 1Z -F-0138-6300 f <br />C-57 Contractor ACX �iC Address ' vik� Carl: City `�`_Z dql Lic# jj] I( .Phone# iiL >V-45 <br />Consultant / Sub C <br />GIS Coordinates: <br />Cityt,,j,"I'-Lic#Phone# <br />, Y , Township Range <br />Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />SOIL BORING `# 0 OVER -BORE. DIAMETER <br />WELL # f AW dV1 tAj 0 PRESSURE GROUT <br />0 *10ther GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE 8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: -2 <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5,jALjt5 TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALi� �ZI� TREMIE TYPE TO BE USED: XAUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes kNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS t C.CY",uI Ir <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH tf j� BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED /Lt0 (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 Ordi ances, Ru es and Regulations, and all applicable California State Laws. <br />Signed x t Title/Company i7 jijfLt IL <br />Print Name �� llll l�'If Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 1:5 !0 0 0 r' "� t L e+-� <br />WORK PLAN DATED: J /S TD --5- <br />Application Accepted By —// J Date Issued ! [ �3 -s —Area <br />Groulrr pe tion By Date 14!?J65 Final Inspection By Date /C% 'fo <br />Destruction Inspection By Date <br />COMMENTS ICON <br />ACCOUNTING ONLY: AID# FAC# <� �(� 3 <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIEQUEST # <br />INVOICE <br />so3 <br />4 3C--3 <br />SR# Ll 3 <br />C-57 WC_ -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-001 <br />6/22/04 <br />