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San Joaquin County <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202MITIGATION <br />200S <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd AUG 11*jKT WS7 <br />Well Permit Application J 0777„ <br />ENV lk?otgplcrlT��dT Y <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED /7L A,, I- I i J n �� }� C <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 comp i4tee4th San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />j 11 �Assessors <br />WELL Location t5yes,c4Ch I{,kn ea 1 Cross Street J Jr� t City Lc4i-, p Zip , . JS �;Q? Parcel# ` %—.210 <br />PROPER Y �r <br />Owner rr: 0 -Ifo- f Address 61C'C '.0,A City 4, 01 ' Zip `030 Phone# Z�1- 27--ZZ)Oi'; <br />C-57 Contractor �Wulk Address`'�jl�v►����il� City►�LliI 4 �XZip.1i 11ZLic# i757� Phone# <br />Consultant/ Sub Cntr. Std (Z Address N,17 K1��0 �`tgC,CtC tyQ,,�l a Lic# �'S^ %E�1 Phone# <br />GIS Coordinates: <br />Township <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) <br />SOIL BORING # <br />ELL # A'1 v,; - t C. <br />0 "Other <br />COMMENTS <br />Range Section <br />p DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING OLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _Z _ <br />0 EXTRACTION 0 IR HAMMER/DRIVEN CASING THICKNESS S\ -It Ali; TYPE OF CASING: 0 STEEL ]AVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL j TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes *o (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 11"S t)' C .'Vy- Y} <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH I4 ” XBOLTED 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 Ordinances Rules, and Regulations, and all applicable California State Laws. <br />Signed x ;� V Title/Company 51Clf+ (;tel ; i5f 7t Lt I` <br />Print Name I .,j 11i�1��i'r Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 156000 <br />WORK PLAN DATED: ► 16 t S <br />ApplicationApcepted By q Date Issued 3 ds Area <br />Grout Inspection By�M�ft'Ni�i Date 1 i� dS Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />PE CODES FEE INFO <br />0 <br />71 <br />AID# <br />FAC# r�/� -- <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PER INVOICE <br />3 <br />4364-3 <br />SR# q37 <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 />CZ- <br />C`� <br />O <br />